Barriers to Bonding
Some factors that have the potential to negatively affect the bonding process
include a lack of support, the riskiness of the pregnancy, maternal fatigue, cesarean
birth, and a lack of confidence in parenting abilities (Ross, 2012). If a woman lacks
confidence in her mothering abilities, she is less likely to report a positive emotional
bond to her baby. Research conducted by Ross reported women who have a high risk
pregnancy are also more likely to have a lack of confidence and a more difficult time
with bonding as compared to a woman with a healthy pregnancy. When evaluating
barriers to bonding, it is important to identify the beliefs and perceived barriers held by
both nurses and mothers.
Ferrarelo and Hatfield (2014) conducted a mixed method study involving surveys
and focus groups with postpartum nurses and mothers in order to determine common
causes of barriers to bonding during the postpartum stay. The study focused on both
mothers’ and nurses’ understanding of barriers to skin-to-skin care (SSC) during the
postpartum period. The survey involved 14 postpartum nurses and showed all of the
nurses realized SSC offered benefit to mothers and babies. However, the nurses agreed
mothers and babies did not spend enough time SSC during their hospital stay. The nurses
also ranked the top barriers to bonding during the postpartum period with visitors in the
room (92.8%), others wanting to hold the newborn (71%), mothers not understanding the
importance of SSC (50%), and maternal grogginess (43%) being the top four barriers.
The surveys were also completed by 15 mothers who had given birth within the past 30
days. All mothers believed they had spent enough time SSC and that SSC was very
important. Most mothers did not identify barriers to SSC; however, those that did rated
“others wanting to hold the newborn (20.1%), grogginess (13.4%), and visitors in the
room (6.7%)” as their top barriers (Ferrarello & Hatfield, 2014, p. 58). Two small focus
groups with postpartum nurses revealed further thoughts regarding barriers to SSC. One
nurse voiced having visitors in the room sometimes causes hours go by without a feeding
because mothers are often hesitant to pump and/or feed when family and friends are in
the room. First time mothers may be especially hesitant about disrobing to allow for
breastfeeding and/or SSC. One mother voiced during the focus group that in the hospital,
breastfeeding was all new and she did not feel comfortable attempting it with other
people around. It was observed the amount of time mother/newborn couplets were
interrupted by visitors, staff, or phone calls during the first postpartum day outweighed
the amount of time mothers had alone with their newborn.
Soon after birth, the woman enters a period referred to as taking-in and taking-
hold (Davidson et al., 2012). During this time, a lack of confidence can negatively impact
the maternal-newborn bonding process. The taking-in period involves the new mother
feeling somewhat passive and dependent in the care of her newborn. The taking-hold
phase involves the mother feeling more ready to mother and resume control of her body.
The nurse can play a vital role during these periods to promote maternal confidence. For
example, if the newborn spits up after breastfeeding, the mother may view it as a
personal failure in her parenting abilities. Therefore, the nurse should educate the new
mother that this is not to be viewed as a failure, but rather as a common finding in
newborns. A woman’s parenting confidence may also be depleted if she sees others
handle her newborn proficiently and confidently while she still feels unsure and tentative
due to a lack of experience with newborns. The nurse can encourage the mom and let her
know confidence will come with time. The postpartum nurse should be aware of each
patient’s unique situation and parenting abilities. The education and knowledge regarding
newborn care will also vary greatly from patient to patient. Some mothers will have
strong family support systems and others will not. Therefore, the nurse should assess
each patient’s needs to determine what resources may be appropriate to refer them to if
necessary.
It is also common for women who gave birth via cesarean section to feel angry or
frustrated that they were not able to give birth vaginally (Weisman et al., 2010). Some
women feel disempowered and perceive a cesarean as a devastating loss if their ideal
birth plan involved a vaginal delivery (Udy, 2009). It has been shown that women who
have had cesarean sections have a higher rate of voluntary secondary infertility with the
purpose of preventing another pregnancy. This is often due to their determination that
the physical and emotional trauma was perceived as too much to repeat. One study
showed women who underwent a cesarean section to have their first baby were 12% less
likely to have another baby than women who gave birth vaginally. These findings
exposed the need for nurses to promote the empowerment of women through the
cesarean process and enhance the maternal-newborn bonding during the postpartum
period as much as possible.
Women are also often disappointed when they are not able to hold and breastfeed
their newborn immediately after birth (Phillips, 2013). These emotions negatively impact
the bonding connection during the postpartum period. Therefore, it is important for the
nurse and caregivers to encourage the mom during this time and let her know having a
cesarean section in no way means she is incompetent, but rather it was just the safest
decision for the health of her and the newborn. When a cesarean section is necessary, the
nurse can implement several strategies to promote an optimal bonding experience. Many
birthing units are aware that skin-to-skin contact after a vaginal birth offers a wide range
of benefits for both mother and newborn. However, few hospitals have implemented
skin-to-skin contact in the operating room after cesarean births. Nevertheless, as long as
the mother and newborn are medically stable, there are few cases where skin-to-skin
contact should not be implemented. Anesthesiologists have reported how amazing the
effect of skin-to-skin contact after delivery has on the stabilization of the mother. When a
new mother has her newborn on her chest, her perception of pain is decreased and her
anxiety level significantly diminishes, which results in increased stability of heart rate
and blood pressure. Furthermore, it promotes temperature stability for the newborn which
reduces the stress that hypothermia may cause. When both mother and newborn are
stable, skin-to-skin contact can be one strategy used to promote bonding after a cesarean
section.
Another factor that can significantly influence the bonding process is support
offered by the father and other family members (Young, 2013). Having this support
system raises the mother’s confidence in her parenting abilities and reduces the likelihood
of postpartum depression. When a woman experiences postpartum depression and/or
postpartum fatigue, she is less likely to demonstrate affectionate touching or respond in
loving ways to her newborn’s needs, which leads to negative bonding outcomes
(Weisman et al., 2010). In addition, their newborns are more likely to experience social
functioning deficits, depressed maternal mood, and emotional concerns. Therefore, the
nurse should educate the family about the important role a support system has on the
bonding process and ideas of what can be done to enhance the process.
The postpartum nurse can help combat the effects maternal fatigue may have on
the bonding relationship by promoting opportunities for rest after birth (Davidson et al.,
2012). This may include limiting visitors and providing a comfortable place for the
significant other to sleep to promote a smooth postpartum transition. Though having
visitors in the postpartum room has been shown to be a potential barrier to skin-to-skin
care and breastfeeding, the solution to this is not to ban all visitors. It is healthy and
normal for visitors to be present during the postpartum time. Nevertheless, certain
modifications can be offered to hospital protocols that will optimize bonding. One option
is the promotion of afternoon quiet time during which visitors are restricted and mothers
can enjoy uninterrupted time with their babies (Ferrarello & Hatfield, 2014). When this
was suggested by Ferrarello and Hatfield, both mothers and nurses involved in the study
were enthusiastic about this proposition. Some hospitals, such as Virginia Baptist in
Lynchburg, VA, have adopted quiet hours from 1:30-3:30 pm during which nurses cluster
their care and discourage visiting to allow mothers and babies this time of uninterrupted
bonding (A. Hicks, personal communication, February 1, 2014). Another suggestion is to
provision of privacy signs to hand on the door of hospital rooms during breastfeeding
(Ferrarello & Hatfield, 2014). It has been shown when mothers are provided a privacy
sign, mothers are significantly more likely to characterize breastfeeding as successful. In
order to address the barrier of maternal exhaustion and/or grogginess, the postpartum
nurse can allow the mother’s care partner to hold the newborn skin-to-skin to allow the
mother time to rest and recover from medication therapy. Mothers can also be provided
with a specialized garment to wear that keeps the newborn skin-to-skin without the risk
of the newborn falling. These measures will promote optimal levels of energy for the
mother to participate in active bonding.
An additional series of barriers to the bonding process occurs when a newborn is
born preterm or unhealthy (Fegran, Helseth, & Fagermoen, 2008). Newborns who
require immediate care in an intensive care nursery are often separated from the mother
immediately after birth. Therefore, premature newborns are considered to be at a high
risk for having a negative bonding experience, primarily due to the fact that most
premature newborns have to spend their first few days of life under neonatal intensive
care. This separation can interfere with the normal maternal-newborn attachment
process (Davidson et al., 2012). When the first few hours of life include intubation,
resuscitation, and oxygen therapy, the newborn and mother miss out on the peak time of
bonding during the first hour after birth. When the health of the mother or newborn
prevents extensive amounts of bonding during the first postpartum hour, other
considerations of ways to get creative with bonding techniques can be given. Many
mothers of preterm newborns are able to have skin-to-skin contact with their newborn
for short periods of time while their newborn is in an intensive care nursery. However, if
the newborn is in an incubator and cannot be held due to medical instability, the mother
can be encouraged to stroke the newborn’s hand, foot, or cheek in an aseptic manner.
Dr. David Wheeler, professor of Evangelism at Liberty University, and his wife
Debbie, have experienced the difficulties of bonding with a premature newborn (David
Wheeler, personal communication, February 10, 2014). Dr. Wheeler and Debbie spent
about 10 weeks in a neonatal intensive care unit (NICU) with their daughter Kara when
she was born at 26 weeks gestation. Weighing only 1 pound 10 ounces, Kara’s life was
very fragile and Debbie was not allowed to hold her as much as she would have liked.
The bonding process was further hindered by Debbie’s critical health condition after
birth. Debbie required several weeks of respiratory intensive care after her delivery with a
condition called granulomatosis with polyangitis. However, Dr. Wheeler emphasized
several interventions the nursing staff implemented which allowed bonding to take place.
Kangaroo care between Debbie and Kara was not allowed because Debbie was in the
respiratory intensive care unit and had a chest tube in. However, Debbie was allowed to
hold Kara’s hand when Kara was three days old which was a very special moment of
bonding for both of them. This was a time where Debbie felt a strong connection with her
newborn, and it also alleviated some of the stress they were feeling while having a
daughter in intensive care. Dr. Wheeler also pointed out ways to promote bonding that do
not involve physical touch. When parents experience an unexpected premature birth,
there are often numerous questions they will have, and their confidence in parenting skills
is likely to be low. However, nurses and doctors can promote bonding by educating the
family about every procedure being done to the newborn. For example, when Dr.
Wheeler went to visit Kara in the NICU, he found the IV in Kara’s scalp vein to be
frightening initially. However, the nurses explained the purpose of the IV and ensured
him it was not causing her any additional pain. Kara later developed an infection, and the
nurses were honest but encouraging about her condition. The staff explained how it was
very common for newborns of her age to develop this and they expected her to return to a
state of health with the antibiotics. The Wheelers said having the staff explain Kara’s
condition was very comforting and helped them bond with Kara. Part of the stress a
newborn feels while in a newborn nursery comes from the stress the parents are feeling.
Therefore, by reducing the amount of stress felt by the parents, the bonding process can
be strengthened.
Being separated from Kara was very hard for Debbie (Debbie Wheeler, personal
communication, February 23, 2015). She wanted to be able to be in the NICU holding
her newborn, but her condition was not stable enough to allow it. The hospital staff
recognized Debbie’s desire to bond with her newborn and did everything they could to
enhance their relationship. They took pictures of Kara frequently and would bring them
to Debbie in the ICU so she could see updates of her newborn. Debbie explained that the
first time she saw pictures of Kara, she cried because she thought Kara was in pain.
However, the nurses assured her she was not. Debbie had a tracheostomy tube that
prevented her from being able to speak. However, she was able to write questions for the
nurses and doctors to respond to. The NICU staff also accepted pictures of the Wheeler
family to post around Kara’s isolette so when members of the Wheeler family would
come to visit, the NICU staff could recognize them and introduce them to Kara. This
promotion of therapeutic communication played a key role in the bonding between Kara
and Debbie.
The Wheelers emphasized engaging the entire family in the bonding process is
important when the health of the mother prevents her from being able to be with her
newborn as much as desired (David Wheeler, personal communication, February 23,
2015). Keeping the family and parents engaged was a great contribution to the bonding
process. When Dr. Wheeler described the NICU, he mentioned how there were very
few fathers there. He emphasized through difficult situations, it is important to involve
the family in the bonding process to build a support system.
Another action the hospital staff did to promote bonding during the Wheeler’s
NICU experience is they provided the Wheelers with a list of other parents who had
children in the NICU (David Wheeler, personal communication, February 10, 2014)..
This provided a network of encouragement for the family as they could hear testimonies
from other families who had children in the NICU in the past. These families were able
to offer encouragement for Debbie and Dr. Wheeler which helped them strategize ways
to bond with Kara. Therefore, when opportunities for physical touch are limited, maternal
newborn bonding can still take place
Nurses who are caring for couplets with the newborn in the NICU should consider
ways to unite the mother with her newborn as soon as possible (Davidson et al., 2012). If
the mother’s health prevents her from taking a trip to the NICU, the nurse can offer to
take pictures and/or video clips of the newborn and show them to the mother in order to
reassure her of the newborn’s status. This combination of education, support, and
creativity can be used to promote a bonding experience as optimal as possible for both
mother and newborn. Postpartum nurses should be aware of any potential barriers to
bonding and be ready to assess for signs of impaired maternal-newborn attachment. Some
signs the nurses should look for include a lack of verbal communication with the
newborn, a hesitant response to the newborn when he or she cries, an apparent distress
over the newborn’s gender or congenital abnormality. If any of these signs are seen, the
nurse can intervene with reassurance, patient education, or role modeling care in order to
promote bonding. However, the nurse should keep in mind individual characteristics such
as values, beliefs, and cultural customs may impact the bonding process.
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