Importance and Benefits of Early Bonding
Before one can be motivated to promote maternal-newborn bonding, the
importance and benefits of bonding must be explored (Young, 2013). The first hour of
life after birth is known to be an optimal opportunity for the maternal-newborn bonding
process to occur. However, this crucial window of time is often taken up by various
medical and nursing procedures such as newborn weights, foot printing, and assessments
which disrupt the bonding process. A newborn’s behavior and subconscious thought
processes can be affected by the early postpartum period (Phillips, 2013). Therefore, it is
critically important for all those involved in the childbirth process including parents,
nurses, and doctors to be aware of the importance of maternal-newborn bonding.
Another reason it is important to promote maternal-newborn bonding is
highlighted by new research showing newborns are capable of forming memories that
remain in their subconscious thoughts for life (Chamberlain, 2013). In his
groundbreaking book entitled Babies Remember Birth, Dr. David Chamberlain compared
the birth stories of 10 mothers with the birth memories of their children. During separate
sessions under hypnosis, mothers and their children were asked to describe the birth
process. Although the children had not been told about their birth history, their accounts
of the events surrounding their births contained many of the unique and specific details
in common with the mother’s account. Dr. Chamberlain’s newest book entitled Windows
to the Womb documented large bodies of research that explore the various ways
newborns and even fetuses are able to demonstrate capacities for learning and memory.
This information is important in several fronts. If newborns subconsciously remember
the first few moments outside of the womb, then how they are treated at birth and during
the first few hours following have a much larger influence on later years in life than most
realize.
Since this parent-child bond is the basis for future bonding experiences, the
importance lies in the maximum quality of the initial bonding experience (Young, 2013).
The quality of the maternal-newborn relationship during the early moments after birth
can have a significant impact on the mother’s mental health and newborn’s well-being,
development, and adaptation throughout life (Johnson, 2013). The unique and long-term
emotional tie that begins with the first contact between the mother and newborn
continues to develop throughout the postpartum period. Therefore, an inadequate mother-
newborn relationship can result in long-term consequences to the child, including
cognitive and socio-economic development, physical health disparities, and difficulties
in personal relationships.
Maternal-newborn bonding can also be beneficial because of its potential to
enhance the development of the newborn’s brain (Phillips, 2013). When a newborn is
born, his or her immature brain is only about 25% of the size it will be in adulthood.
Even though all brain cells are present at birth, the myelination and synaptic
development that will take place later in life is not yet complete. Dr. Allan Schore
discovered the maturation of the amygdala undergoes a critical period of development
that begins at birth and continues throughout the first two months of life. Dr. Schore’s
research proclaims skin-to-skin contact after birth activates the amygdala via the
prefrontal orbital pathway. This activation contributes to the maturation of the amygdala.
The amygdala is a part of the limbic system involved in emotional learning, as well as in
seeking love and sustaining long-term emotional memories (Trigoboff, 2013). When
these long-term emotional memories are established due to proper maternal-newborn
bonding, the relationship between mother and child can be enhanced.
Promoting Bonding
Research has shown the first hour after birth is when the strongest foundation for
bonding occurs (Young, 2013). Therefore, childbirth staff need to be cognizant of how to
support bonding during this critical window of opportunity (Henry, Richard-Yris,
Tordjman, & Hausberger, 2009). During the first hour of life, the neonate is most alert
and naturally seeks both suckling and skin-to-skin touch. Therefore, when newborns are
separated from their mother during the first hour of life, the couplet is more likely to
experience a weaker initial attachment to each other. Nurses can promote a positive
bonding and attachment experience by encouraging contact between the mother and
newborn, thereby facilitating a positive emotional mood.
Breastfeeding during the first postpartum hour is one of the best ways to
promote maternal-newborn bonding (McLeod, 2009). One of the reasons why
breastfeeding aids in bonding can be described by the behavioral theory of attachment
by classical conditioning. The behavioral theory of attachment suggests a newborn
forms an attachment with the caregiver who provides food and emotional comfort.
When a newborn is born, he has no immediate attachment to his mother. However,
when he is breastfed, he begins to learn to associate his mother with the comfort of
being fed. Being close to the mother’s breast also creates a sense of comfort for the
newborn that can aid in the bonding process. This is because the baby is born knowing
the smell of amniotic fluid which is similar to the scent of the mother’s breast (Palmer,
2013).Therefore, through the process of classical conditioning, the newborn comes to
find the contact with his or her mother comforting (McLeod, 2009).
Early breastfeeding can also aid in the release of oxytocin by stimulating the milk
let down reflex which can help make the first attempt at breastfeeding more successful.
Nursing a newborn during the first postpartum hour causes an increase in oxytocin levels.
Therefore, when breastfeeding is delayed or never initiated, the couplet loses part of the
hormone peak that takes place immediately after birth (Palmer, 2013). When a newborn’s
hand massages the mother’s breast during a feeding, the mother releases more oxytocin
which further aids in the bonding process (Phillips, 2013). Oxytocin is also transferred to
the newborn through breast milk which promotes continuous relaxation and closeness for
both mother and baby (Palmer, 2013). Kayla Johnson (2013) found mothers who initiated
breastfeeding within the first two hours after birth seemed more content and confident in
their parenting abilities at one year after birth. The emotion and love formed during these
early moments greatly enhance the maternal-newborn bond (Bussel, Spitz, &
Demyttenaere, 2010). When oxytocin and prolactin hormones are released during
breastfeeding within one hour of the delivery on maternal- newborn bonding. A total of
218 couplets were enrolled in their study. The control group consisted of 109 couplets
who initiated breastfeeding more than one hour after birth. The experimental group
consisted of 109 couplets who did initiate breastfeeding within one hour of birth. During
the experiment, mothers were not forced to initiate breastfeeding immediately nor delay
the initiation for the sake of the experiment. Instead, mothers were contacted one hour
after the delivery of their newborn and asked when they initiated breastfeeding. If it was
within one hour of delivery, they were placed in the experimental group. If it was more
than one hour, they were placed in the control group. Maternal-newborn bonding was
assessed at 24 and 48 hours after delivery using the Maternal Postnatal Attachment Scale.
The Maternal Postnatal Attachment Scale was developed by John Condin and
Carolyn Corkindale in 1998 (Condon & Corkindale, 1998). The self-report
questionnaire features 19 questions that address areas of bonding and attachment such as
“pleasure in proximity, acceptance, tolerance, and competence as a parent” (Condon &
Corkindale, 1998, p. 57). Using the scale, the control group had a mean bonding score of
73.6, while the experimental group had an average bonding score of 81.1 at 24 hours
after delivery (Himani et al., 2011). At 48 hours postpartum, the control group had a
mean bonding score of 74.5 and the experimental group had an average bonding score of
83.3. It is acknowledged that quantifying the maternal-newborn bonding is a difficult
challenge for researchers because it involves the psychological study of the mother and
her attachment to the neonate. Upon results analysis, a significant difference was found
between the maternal newborn bonding scores of the control and experimental groups.
The research team recommended that breastfeeding be initiated within one hour of
delivery, as long as maternal and newborn health allows, in order to promote optimal
maternal-newborn bonding. The establishment of early breastfeeding can encourage a
high quality maternal-newborn attachment throughout infanthood. During the first
postpartum hour, the newborn is most alert and the sucking reflex of the neonate is the
most active. Therefore, when babies are put to breast during the first hour after delivery,
the mother and newborn are able to take advantage of this peak time. Not only are
newborns particularly alert and apt to breastfeed during the first postpartum hour, but
new mothers are also particularly sensitive during the immediate postpartum period.
Therefore, the early first contact of mother and newborn seems to optimize attachment
and bonding of the mother to the newborn.
Himani et al. also conducted a study to find the relationship between early
initiation of breastfeeding and the long term success of breastfeeding. The study involved
111 primiparous women who intended to breastfeed their newborns. These women were
placed into groups that were matched for social class and age. The sample was divided
into two groups, with half of the women breastfeeding within 10 minutes of birth and the
other half initiating breastfeeding four to six hours after birth. Results showed the group
who began breastfeeding within minutes of delivery breastfed their newborns for an
average of 161 days, which was 40% longer than the group who initiated breastfeeding
several hours after birth. This is a difference of about 96 days. Therefore, it can be
recommended that early contact between mothers and newborns is promoted in order to
maximize bonding during this maternal sensitive period. Himani et al. (2011) concludes
that “Prolonged breastfeeding appears to be one of the outcomes of promoting early
contact of mother-newborn pairs” (p. 101). Because breastfeeding is a significant source
of bonding throughout infanthood, these results are important to consider.
An additional way to promote bonding is through the encouragement of eye
contact between the mother and newborn during the first hour after birth (Davidson,
London, & Ladewig, 2012). After birth, the new mother should increase the proportion of
time she spends in the en face position with her newborn. The en face position involves
direct face-to-face and eye-to-eye contact between the mother and newborn. When the
newborn’s eyes are open, the mother instinctively greets the newborn and talks in high
pitched tones to him or her. These are signs that active bonding is taking place. The nurse
can play a vital role in promoting the effects of this eye contact after birth. For example,
nurses can delay the administration of Erythromycin in the newborn’s eyes until this
critical hour has passed in order to avoid clouding the vision of the newborn.
Maternal-newborn bonding can also result from positive moments of maternal-
touch-massage during the first postpartum hour (Feldman et al., 2011). Mothers can be
encouraged to use newborn massage as a way to increase the bonding and relaxation
process during the postpartum period (Arivabene, 2010). In a study done by Field, Diego,
and Hernandez-Reif (2010), the effects of newborn massage during the postpartum period
were explored. During the experiment, newborn newborns were randomly assigned to a
massage therapy or to a control group. The experimental group using massage therapy
received three, 15-minute massages each day for five consecutive days. The massage
consisted of moderate pressure stroking to the shoulders, back, head, legs, and arms as
well as kinesthetic exercises involving extension and flexion of the limbs. The study
found newborn stress behaviors and activity were significantly reduced which suggests
massage has a pacifying and stress-reducing effect on newborn newborns. This can
beneficially assist the bonding process because it can relieve some of the stress that
accompanies delivery. As a part of postpartum newborn massage, the nurse can
encourage the mother to familiarize herself with her newborn through fingertip
exploration of the newborn from head to toe (Davidson et al., 2012). The mother can also
familiarize herself with the newborn through a sense of sight, touch, and hearing.
Mothers who participate in infant massage are more likely to respond verbally to any
sounds emitted by the newborn such as cries, coughs, sneezes, and grunts. These verbal
responses also indicate active bonding is taking place.
Finally, skin-to-skin contact, also known as kangaroo care, between the mother
and newborn has been shown to be associated with a wide variety of physical and
psychological benefits for both the newborn and mother (Brimdyr, 2011). When a
newborn is allowed to have uninterrupted skin-to-skin contact with his or her mother
after birth, the newborn goes through nine instinctive stages during the first postpartum
hour that promote bonding and attachment early on. Stage one involves the birth cry that
allows the newborn’s lungs to expand. The second stage consists of relaxation when the
newborn demonstrates few movements. Next is the awakening stage which typically
occurs while the newborn is three to eight minutes old. During this stage, the newborn
exhibits small thrusts of movement in the head and shoulder. The fourth stage is the
activity stage where the newborn demonstrates the rooting reflex while making
increased mouthing and sucking movements.
The stage of rest follows, during which the newborn is likely to sleep. Stage six
generally occurs 35 minutes after birth and consists of the newborn crawling towards
the breast to reach the nipple. This is when it is especially important that the breast is
made available to the newborn in order to take advantage of this peak time of activity.
The seventh stage begins about 45 minutes after birth and involves the newborn
becoming familiarized with the mother by massaging her breast and licking the nipple.
This stage can last up to 20 minutes. Following is the eighth stage, during which the
newborn generally self attaches to the nipple and suckles. This is a vitally important
early experience of learning to breastfeed. Within 1.5-2 hours after birth, the newborn
will enter into stage nine which is the sleep stage. If at any point during the first
postpartum hour the newborn is lifted from the mother’s chest, the newborn will become
distressed and disoriented and will have to restart the nine instinctive stages, which
delays breastfeeding success (Phillips, 2013). Therefore, if the newborn is not skin-to-
skin during the first hour after birth, the peak opportunity to promote bonding will be
missed.
Skin-to-skin contact allows for several physiologic benefits that all contribute to
maternal newborn bonding during the postpartum period (M. Fitzgerald, personal
communication, February 25, 2015). One pertinent benefit of skin-to-skin contact after
a vaginal delivery is the analgesic effects it can have for the mother. The time period
immediately following a vaginal delivery can be quite painful for the mother due to
frequent fundal massages and any tearing that occurred to the perineal area during
delivery. However, having the newborn lay prone on the mother’s chest after birth is an
excellent distraction to the pain the mother may be experiencing.
Studies by Arivabene (2010) showed when the mother has direct skin-to-skin
contact with her newborn during the first postpartum hour, the newborn later shows
reduced levels of plasma cortisol levels when compared to newborns who have not had
similar skin-to-skin contact after birth. Cortisol is a hormone released from the adrenal
cortex as a part of the body’s natural response to stress (Lewis & Retherford, 2011).
When the body is stressed, levels of cortisol will increase. Therefore, this reduced level
of cortisol that occurs after skin-to-skin contact represents a reduction in the stress levels
that the newborn experiences. Furthermore, kangaroo contact has been shown to
increase the mother’s confidence in her abilities to respond to her newborn’s needs
(Arivabene, 2010). John Bowlby articulates the defining feature of a secure attachment
is the newborn’s confidence in the responsiveness and availability of the attachment
figure when a need exists (Hazan & Campa, 2013). Therefore, kangaroo care can aid in
this attachment process early on.
Though many benefits of skin-to-skin contact are well known to health care
professionals, many new mothers are unaware of the array of assets it has to offer
(ICEA, 2013). The International Childbirth Education Association (ICEA) advocates for
childbirth education curriculums to include information regarding the benefits and
practices of skin-to-skin care during the postpartum period ranging from vital sign
stabilization to the promotion of attachment. During classes such as Lamaze, educators
can teach about the benefits skin-to-skin care has to offer for both mother and newborn
including optimal adaptation to extra-uterine life during the first few hours of life. A
new mother is most likely to comply with suggested skin-to-skin contact if she knows all
about the physical benefits it can provide for the newborn. Therefore, in an effort to
promote maternal-newborn bonding, nurses can educate the mother about the
physiologic profits skin-to-skin contact offers to both the mother and newborn.
A study involving 1025 mother-newborn dyads found skin-to-skin contact
immediately following birth helped to stabilize newborn temperature and
cardiorespiratory status, promote breastfeeding, reduce newborn crying and enhance
maternal-newborn attachment (Davidson et al., 2012). Kangaroo care has been shown to
result in better outcomes regarding heart rates, breathing patterns, cerebral and body
oxygenation, metabolism, temperature control, growth, and weight gain when compared
to traditional neonatal care (Anderzen-Carlsson, Lamy, Tingvall, & Erikson, 2014).
Being skin-to-skin with the mother has been shown to stabilize glucose levels in the
newborn, which can reduce the incidence of hypoglycemia commonly seen in newborns,
especially when born to diabetic mothers (Phillips, 2013). Studies have shown this
stabilization of glucose levels and body temperature to occur at a higher rate than babies
left under warmers after birth.
Skin-to-skin contact also helps the newborn maintain an optimal body
temperature which prevents the newborn from experiencing hypothermia, causing
significant stress to the newborn. There is a thermal synchrony phenomenon that takes
place whereby the temperature of the mother’s chest increases to warm a cool newborn
and decreases to cool an overly warm newborn. When a newborn enters the world for the
first time, he or she is wet and easily chilled in the cool extra-uterine environment.
Therefore, the newborn experiences a sense of comfort when warmed by the mother’s
chest, which further enhances the bonding process. Kangaroo care involves laying the
newborn prone on the mother’s chest, and is one of the simplest ways to support bonding
between the newborn and the mother (Arivabene, 2010). Premature newborns who have
experienced kangaroo care have been shown to have a reduced need for extra oxygen
(Newman, 2009). Preterm newborns requiring oxygen can be cared for skin-to-skin
while receiving oxygen therapy.
If the mother’s health prevents the possibility of doing skin-to-skin contact
immediately after birth, babies can be held to the chest of the father or other family
member to stabilize temperature and glucose levels until the mother is stabilized
(Phillips, 2013). In addition, skin-to-skin contact between mother and newborn directly
after birth also allows for the newborn to be colonized by bacterial similar to the flora
found in the mother (Newman, 2009). When combined with breastfeeding, the
newborn’s likelihood of developing various allergic diseases decreases. When a newborn
is put into an incubator, the skin and gut are often colonized by bacteria different from
the mother’s.
Furthermore, kangaroo care has been shown to decrease episodes of crying and
increase the amount of time the newborn spends in the quiet alert state (Phillips, 2013).
Meta-analyses have demonstrated improved rates of breastfeeding, mother newborn
attachment, and improved maternal-newborn interaction in couplets who have utilized
skin-to-skin care (Conde-Agudelo, Belizan, & Diaz-Rossello, 2014). Moreover, skin-to-
skin contact increases oxytocin levels. Oxytocin is sometimes referred to as the
hormone of attachment (Phillips, 2013). Johnson (2013) reported mothers who
participate in immediate skin-to-skin contact are more sensitive to the needs of their
newborn one year after birth when compared to women who did not.
Humans are not the only species that have a critical period of bonding and
attachment during the first few hours after birth (McLeod, 2009). It has been discovered
that geese follow the first moving object they see during a critical period that takes
place approximately 12-17 hours after hatching which suggests attachment is actually
innate and programmed genetically. This event involving powerful imprinting for both
mother and baby ideally occurs during the first postpartum hour so that mother and
baby can recognize each other in the first week after birth (Palmer, 2013).
Nurses can also play a role in supporting maternal psychosocial well-being as a
way of encouraging maternal-newborn bonding (Davidson et al., 2012). Becoming a
mother involves an extensive amount of role changes and increased responsibilities.
These can increase the emotional stress of a new mother and hinder the bonding process.
Becoming a mother is a life-transforming process through which mothers establish
maternal identity, including commitment, attachment, preparation, acquaintance,
learning, physical restoration, and achievement of the new maternal identity. This process
requires extensive psychological, social, and physical work which requires the support of
the postpartum nurse. Therefore, an interactive nurse-patient relationship is an excellent
way to promote maternal-newborn bonding. The postpartum nurse can also promote
maternal-newborn bonding by allowing the mother to participate in the newborn’s care as
much as possible. Many hospitals are promoting rooming-in couplet care where the
mother and newborn stay in the same room as a couplet instead of the newborn staying
primarily in a newborn nursery after birth. Couplet care allows the nurse to teach and role
model the care of the newborn so the mother can have time to bond with her newborn and
learn to care for him or her in a supportive environment. The role of the postpartum nurse
should include encouraging the mother to be involved in any nursing interventions,
planning, and evaluation with choices offered as much as possible. If the newborn is not
being breastfed, the mother should be encouraged to bottle feed her newborn for each
feeding, rather than the nurse. The nurse can educate the mother about how breastfeeding
should be done in an on-demand feeding schedule while the couplet is on the mother-
newborn unit. The mother should also be encouraged to participate in the newborn’s first
bath and in diapering the newborn as needed. These efforts to encourage maternal
involvement will increase the mother’s self-confidence about her effectiveness as a
parent. Nurses can offer positive feedback to the mother as she provides care for her
newborn. Mothers need to hear it takes time, trial, and error for both mother and newborn
to know what to expect of the other and how to meet each other’s needs.
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