Lifetime and antenatal predictors of post-partum psychopathology: a focus on maternal bonding and previous depressive episode

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UNIVERSITÀ DI PISA

Dipartimento di Medicina Clinica e Sperimentale

Scuola di Specializzazione in Psichiatria

Direttore Prof.ssa Liliana Dell’Osso

Tesi di Specializzazione

Lifetime and antenatal predictors of post-partum psychopathology:

a focus on maternal bonding and previous depressive episode

Relatore

Prof. Giulio Perugi

Candidato

Dott.ssa Eleonora Petri

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ABSTRACT

Introduction: Depressive mood disorders affect approximately between 8.5% and 10% of the women during pregnancy and between 6.5 and 12.9% of the women in the first post-partum year. Poor maternal attachment has been associated with the occurrence of depression during gestation and post-partum. Both perinatal depression and maternal attachment seems to be important for infant’s social, emotional and cognitive development. Several risk factors, including antenatal psychopathology and the personal history of depression, have been identified as predictors of maternal depression. Some studies reported that also the quality of the maternal-foetal attachment may play a role in determining post-partum depression. The aim of this study was to evaluate the association of maternal antenatal attachment with post-partum psychopathology and maternal-infant bonding, while checking for antenatal psychopathology and for lifetime psychiatric diagnosis. Further aim of the study was to evaluate the correlation between previous depression and the occurrence of maternal antenatal and postnatal psychopathology.

Methods: One hundred-six women recruited at the first month of pregnancy (T0) were evaluated with the structured interview for DSM-IV TR (SCID-I) to assess the presence of lifetime psychiatric diagnosis and completed the Perinatal Depression Predictor Inventory-Revised (PDPI-R), the Edinburgh Postnatal Depression Scale (EPDS) and the State-Trait Anxiety Inventory (STAI). At the sixth month of pregnancy (T1) and at the first month post-partum (T2), all patients completed self-evaluation with the PDPI-R, the EPDS, the STAI, and the Maternal Antenatal Attachment Scale (MAAS), only at T1, and the Maternal Postnatal Attachment Scale (MPAS), only at T2.

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Results: Univariate regression analyses showed that the maternal-foetal attachment was the variable most significantly associated with postnatal symptoms of depression and anxiety and the quality of maternal-infant attachment. The logistic regression analysis showed that antenatal attachment predicted postnatal depressive (OR: 0.83 – IC [0.74-0.95], p=0.005) and anxious symptoms (OR:0.88 – IC [0.79-0.98], p=0.02), and maternal postnatal attachment (OR:1.17 – IC [1.08-1.27], p<0.001), also after controlling for the known risk factors and lifetime psychiatric diagnosis. The history of lifetime mood disorders was associated with the occurrence of depressive symptoms at the first month of pregnancy (OR: 1.23 – IC [1.06-1.43], p=0.006) and at the first month post-partum (OR: 1.16 – IC [1.02-1.32], p=0.024).

Conclusion: The quality of maternal-foetal bonding may independently predict the quality of maternal-infant attachment and post-partum depressive and anxiety symptoms. The history of depression is associated with the onset of depressive symptoms at the beginning of pregnancy and in the early post-partum. A comprehensive assessment of maternal risk factors for perinatal psychopathology during pregnancy should include the evaluation of maternal-foetal attachment. In fact, maternal antenatal attachment differently from other variables, such as the history of depression, could be modifiable by specific interventions promoting the quality of bonding.

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INTRODUCTION

The term “perinatal depression” is used to describe a continuum of depressive symptoms and diagnoses that occurs during pregnancy and in the post-partum period. Depression has been shown to affect approximately from 8.5% to 10% of women during gestation and from 6.5% to 12.9% in the first year of the post partum period (Gaynes et al., 2005). Perinatal affective disorders also include anxiety disorders during pregnancy and in the postnatal period, which often occur in comorbidity with perinatal mood disorders. Perinatal depression may impact on the well-being of the mother leading to risky behavior and to poor self-care (Alhusen, Ayres, & DePriest, 2016; Zuckerman, Amaro, Bauchner, & Cabral, 1989). Maternal depression can also impact on the infant development starting from the uterus life throughout adulthood. In particular, perinatal depression may negatively affect emotion regulation, stress reactivity, and cognitive processes in the child from early to adult life (Feldman et al., 2009; Hay, Pawlby, Waters, & Sharp, 2008; Righetti-Veltema, Bousquet, & Manzano, 2003). Several risk factors, including antenatal psychopathology and the personal history of depression, have been identified as predictors of maternal post-partum depression (Robertson, Grace, Wallington, & Stewart, 2004). Some studies reported that the quality of the maternal-foetal attachment during late pregnancy may also play a role in determining the post-partum psychopathology (Alhusen, Hayat, & Gross, 2013; Figueiredo & Costa, 2009). Antenatal attachment has been defined as the specific bond that parents develop towards the fetus during pregnancy. Since Winnicott’s (1958) conceptualization of the “primary maternal preoccupation”, the quality of the antenatal emotional bonding has been recognized as particularly important for the subsequent attachment relationship and for the infant’s psychological development. Cranley is the formal creator of the construct of antenatal attachment, defined as “the extent to which

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women engage in behaviors that represent an affiliation and interaction with their unborn child”. Research on maternal attachment has its roots in Bowlby’s attachment theory that defined attachment as a set of evolutionary behavior aimed at promoting the proximity between the caregivers and the infant. The subsequent works of Mary Ainsworth introduced the term “sensitivity” referring to “the maternal behaviors that revealed the mother’s degree of engagement with the emotional world of the infant” (Ainsworth, 1978). A good quality of the antenatal maternal bonding seems to be important for the well-being of both mother and child. Poor maternal antenatal attachment has been associated with maternal risky behavior and poor health care (Lindgren, 2001, 2003; Sedgmen, McMahon, Cairns, Benzie, & Woodfield, 2006). Women reporting poor attachment during pregnancy had an increased risk of giving birth to an infant with adverse neonatal outcomes (Alhusen, Gross, Hayat, Woods, & Sharps, 2012) and less optimal early childhood development (Alhusen et al., 2013). Disordered maternal attachment may also negatively impact on the child brain regulatory functions, thus negatively affecting their subsequent mental health (J. Green & Goldwyn, 2002; Patock-Peckham & Morgan-Lopez, 2010; Warren, Huston, Egeland, & Sroufe, 1997). Some studies have evaluated the association between the quality of maternal attachment and perinatal psychopathology. Perinatal depression has been correlated with a poor quality of maternal bonding during both pregnancy and postpartum (Alhusen, Gross, Hayat, Rose, & Sharps, 2012; Damato, 2004; Goecke et al., 2012; Lindgren, 2001; McFarland et al., 2011; Ohoka et al., 2014; Ossa, Bustos, & Fernandez, 2012). Also anxiety symptoms during pregnancy (Garcia et al., 2002; Hart & McMahon, 2006; Hsu & Chen, 2001; Segdmen, 2006) and in the post-partum period (Feldman, Weller, Leckman, Kuint, & Eidelman, 1999) have been associated with poorer maternal attachment. However, the role of antenatal bonding in determining post-partum psychopathology has not been clearly established yet. Some studies have

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shown a correlation between antenatal and postnatal maternal-child attachment: higher quality of bonding during pregnancy seems to predict a higher quality of bonding in the postnatal period (J. T. Condon & Dunn, 1988; Damato, 2004; Rossen et al., 2017; Rossen et al., 2016; A. Siddiqui & Hagglof, 2000), although the role of antenatal attachment in determining post-partum maternal-infant bonding remains unclear. Understanding the mechanisms involved in both the development of maternal psychopathology and of the quality of bonding in the post partum period should be a priority for warranting both mother and infant health.

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CLINICAL FEATURES OF MOOD AND ANXIETY DISORDERS

IN THE PERINATAL PERIOD

Although psychiatric disorders in the post-partum period have been described since the time of Hippocrates, only in the past fifty years the attention has been focused on the non-psychotic mental illness experienced by women in the perinatal period. In the literature of the 1960s, only few papers used the terms “post-partum depression”, “postnatal depression”, or “perinatal depression”. These definitions came into common use in the 1970s, but the vast majority of the studies regarding antenatal and postnatal depression was published in recent years (Pariante, 2014). Post-partum psychiatric disorders include three main categories, often related and overlapping: maternity blues, postpartum depression, and postpartum psychosis. Maternity blues represents a relatively mild, self-limiting mood state that occurs within the first two weeks postpartum in among 50% to 80% of the women. Although the maternity blues is considered as a normal sequelae of childbirth, women who experience maternity blues appear to be at greater risk for depression in the first postpartum year. In contrast, postpartum psychosis1 is a relatively rare condition, with an incidence of 0.1% to 0.2%, that occurs typically within the first four weeks after childbirth and constitutes a medical emergency. The third category of postpartum psychiatric disturbances is postpartum depression. In clinical studies the term “postpartum depression” has often been used to describe a very heterogeneous range of affective disorders (Wisner,

1_{Post-partum psychosis is the most severe postpartum psychiatric disorder and is characterized}

by a significant risk for both the mother and infant. The estimated suicide rate was of 2 per 1000 sufferers. Some clinical features make post-partum psychosis atypical compared to other psychosis or manic episodes, because of the typical rapid onset, the mood lability, the unusual psychotic symptoms, often mood incongruent. The confusion, the cognitive disorganization and the olfactory, visual and tactile hallucinations make puerperal psychosis often more similar to an organic syndrome.

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Moses-Kolko, & Sit, 2010). A growing body of research has characterized the clinical presentation, prevalence and treatment of major depressive disorders in the post-partum period, but in recent years, much of the attention has been focused also on maternal mood disturbances during pregnancy (Robertson et al., 2004). With the term perinatal depression researches defined affective episode occurring during gestation up to one year after childbirth. Perinatal depression may include recurrent depression unrelated to childbearing as well as depressive episodes chronologically or biologically linked to pregnancy or post-partum. In fact, many women may enter pregnancy while experiencing a major depression or may develop a new onset depressive episode during pregnancy that could end during pregnancy or carry over to the post-partum period, or may develop a new depressive episode in the post-partum period (Pariante, 2014). On the other hand, in the perinatal period many women frequently exhibit a variety of sub-threshold depressive symptoms, often with a comorbid anxiety disorder. In fact, it is likely that post-partum depressed women also have an anxiety disorder or experience significant symptoms of anxiety.

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Perinatal depressive disorders

The Research Diagnostic Criteria (RDC) (Spitzer, Endicott, & Robins, 1978) identified three frameworks for different forms of postpartum depression arranged on a continuum differentiable in terms of severity of symptoms, course and prevalence: the maternity blues, minor depression (mild, neurotic or atypical) and major depression.

The maternity blues was described for the first time by Yalom (1968) and Pitt (1973) as a transient state of emotional dysphoria, emerging within a few hours to two week after childbirth, that occurs in 50 to 70% of puerperal women and is characterized by intermittent mild fatigue, tearfulness, worry, difficult in thinking, and sleep disturbances. During the first days after delivery, progesterone and oestrogen levels, which gradually increase during pregnancy, fall suddenly returning to pre-pregnancy levels in just three days. This rapid decline has been supposed to be one of the main causes of post-partum/maternity blues (Pitt, 1973; Yalom, Lunde, Moos, & Hamburg, 1968). Women with postpartum blues often present a personal or family history of depression, premenstrual dysphoric disorder, and recent stressful life events or poor social support. Maternity blues has been also correlated with the presence of depressive or anxious symptoms during pregnancy (Hamilton, 1989). Around 20% of women presenting postpartum blues may have a depressive episode during the first year post-partum (Najman, Andersen, Bor, O'Callaghan, & Williams, 2000). Furthermore, maternity blues has been associated with an increased risk of major depression and anxiety disorders in the three months following childbirth (Reck, Stehle, Reinig, & Mundt, 2009). The mother’s behavioural sensitivity to the decline of reproductive hormones has been later associated also with a higher reactivity of the mother to the infant’s stimuli, that may have a role in promoting the proximity to the neonate (Barrett & Fleming, 2011; Carter, 2005). In this sense, it has been hypothesize that these

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hormonal fluctuation might play a role in the development of the mother to infant attachment, ensuring that the infant receives the required care to survive (Carter, 2005). The rates of antenatal depression, assessed using interview and self-report data, were 7.4% in the first trimester, 12.8% in the second trimester, and 12% in the third trimester (Bennett, Einarson, Taddio, Koren, & Einarson, 2004a). Reporting only studies using assessment with diagnostic criteria, Gavin reported a point prevalence range of 8.5% to 11% for major and minor depression, respectively (Gavin et al., 2005). Postpartum non-psychotic depression is the most common complication of childbearing, affecting approximately 13% of women (Gaynes et al., 2005) of childbearing age. Estimates of prevalence in teenage mothers are much higher at 26% (Troutman & Cutrona, 1990). Postpartum depression usually begins within the first six weeks following delivery, and in most cases requires treatment by a health professional. In others, a period of well-being after delivery is followed by a gradual onset of depression. Recent evidences from epidemiological and clinical studies suggest that mood disturbances following childbirth are not significantly different from affective illnesses occurring in women at other times in their lives (Cox, Murray, & Chapman, 1993; R. Kumar & Robson, 1984). Also from a clinical perspective, postpartum depression (PPD) is not distinguishable from other types of non-psychotic major depression. The majority of postnatal depressions are self-limiting, resolving within months of onset (R. Kumar & Robson, 1984). However, for many women childbirth is the stressor that triggers the start of recurrent or chronic episodes of depressive disorder. Women who have experienced postpartum depression are at risk of suffering further episodes of illness, both following subsequent deliveries and also unrelated to childbirth (R. Kumar & Robson, 1984; Nott, 1987).

The clinical picture of post-partum depression is typically characterized by the presence of depressed mood, tearfulness, irritability and loss of interest in usual activities. Also

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insomnia, fatigue and loss of appetite are frequently described. Differently from the typical presentation of major depression, women with post-partum depression often express excessive worries about the health of the child, the ability to feed and take care of him, ambivalent or negative feelings toward their infant, or the feeling of not loving the child (Cox et al., 1993). Although symptoms of post-partum depression are comparable to that of major depression, the presence of weight reduction, sleep disturbances and loss of energy are often attributed to the physiological consequences of childbirth. Therefore, distinguishing between depressive symptoms and the supposed “normal” sequelae of childbirth may be a challenge in clinical setting. Failure to recognize postpartum mood disturbance can sometimes lead to tragic consequences for the mother and child, particularly maternal suicide and infanticide. Although suicidal ideation is frequently described, suicide rates appear however to be relatively low in women with non-psychotic major depression (Nonacs et al., 2005).

In the previous edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, American Psychiatric Association, 2000), a diagnosis of postpartum depression could be made when the clinical picture, with persistent depressed mood or loss of interest and pleasure, lasts for at least two weeks or greater. To make the diagnosis was necessary the presence of five or more of the following symptoms: insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, changes in appetite, feelings of inadequacy and guilt, impaired concentration, and suicidal ideation. DSM-IV-TR indicates that the onset of the symptoms of depression must occur within four weeks after delivery; however, many researchers agree to include in the definition of postpartum depression all the depressive episodes beginning within one year after childbirth (Gaynes et al., 2005). The Diagnostic and Statistical Manual of Mental Disorders (DSM-5, APA, 2013) utilizes the specifier “with peripartum onset” if the onset of mood symptoms occur during pregnancy or within the four weeks following

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delivery. The International Classification of Diseases (ICD-10) uses a 6-week time-frame for “mental and behavioural disorders associated with the puerperium, not elsewhere classified”. However, despite any official diagnostic nomenclatures, clinical studies have included in the definition of “perinatal depression” depressive episodes occurring during pregnancy and up to one year after delivery.

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Perinatal anxiety disorders

Although pregnancy has been suggested to play a protective role towards some anxiety disorder such as panic disorder (Robertson et al., 2004), a recent meta-analysis of literature showed a high prevalence of anxiety disorders among pregnant women. Particularly, the prevalence for self-reported anxiety symptoms was 18.2% in the first trimester, 19.1% in the second trimester, and 24.6% in the third trimester. The overall prevalence for a clinical diagnosis of any anxiety disorder was 15.2% and 4.1% for a generalized anxiety disorder. In the post-partum period, the prevalence for anxiety symptoms overall at 1-24 weeks was 15.0%, the prevalence for any anxiety disorder over the same period was 9.9%, and for a generalized anxiety disorder was 5.7% (Dennis, Falah-Hassani, & Shiri, 2017a). Other empirical studies reported a high prevalence of anxiety symptoms in more than 25% of pregnant women (Britton 2011; Ross and McLean 2006). However, researchers highlighted that there is a considerable variability in prevalence estimates for specific disorders and for any anxiety disorder among the studies (Goodman, Chenausky, & Freeman, 2014). Some studies reported that anxiety levels seemed to be higher during pregnancy when compared to the postpartum period (Andersson, Sundstrom-Poromaa, Wulff, Astrom, & Bixo, 2006; Buist, Morse, & Durkin, 2003; Figueiredo & Costa, 2009). Reck and colleagues (Reck et al., 2008) reported a prevalence rate of 11.1 % for postpartum anxiety disorders which is higher than the rate of 6.1 % found for postpartum depressive disorders. Around one third of women diagnosed with post-partum depression also met criteria for an anxiety disorder and appeared to be most commonly affected by generalized anxiety disorder (Nonacs et al., 2005). The postpartum period may be often accompanied by the onset or the exacerbation of anxiety disorders. The onset of symptoms of panic disorder (Metz, Sichel, & Goff, 1988) associated with the fear to harm their baby is a condition

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defined as 'postpartum panic' and represent in most cases a mild condition, usually managed without the need for specific interventions.

Women with postpartum depression are more likely to experience intrusive, obsessive ruminations and comorbid obsessive-compulsive symptoms (Miller, Hoxha, Wisner, & Gossett, 2015). Abramowitz and colleagues (Abramowitz et al., 2010) reported that 87% of women presenting a perinatal mood disorder had intrusive, obsessive-like thoughts, with half of those women experiencing clinically significant obsessions. In new mothers, checking behavior might be considered adaptive with respect to vigilance about the newborns’ wellbeing; however, in OCD, it is intensified to a degree that compromises the maternal caretaking function (Wisner, Peindl, Gigliotti, & Hanusa, 1999). In one study, half of women with obsessive-compulsive disorder reported that the birth of a child was the precipitant of the illness (Maina, Albert, Bogetto, Vaschetto, & Ravizza, 1999); similarly, in another study, half of women with preexisting obsessive-compulsive disorder reported a worsening of symptoms in the postpartum period (Labad et al., 2005). Women are very distressed by these thoughts, the compulsions may not manifest as an active ritual but may occur as avoidance of the feared situation (harming the newborn) by asking others to care for the baby or avoiding behaviors or objects associated with obsessions. The obsessions frequently involve the child and are frequently characterized by aggressive ego-dystonic thoughts, for example about smothering the infant, dropping it down the stairs, or throwing it out of the window. In a study of women with postpartum major depression (Wisner et al., 1999), 57% reported obsessive thoughts concerning harm to their babies, and the majority had checking compulsions (that they had not harmed their babies, that nothing terrible had happened).

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Perinatal depression risk factors

Several studies have investigated the role of some biological and psychosocial factors in determining the onset of antenatal and postnatal maternal psychopathology. Two important meta-analyses (Beck, 2001; O'Hara, 1996) have been conducted on more than seventy studies, examining about 12.000 research subjects of different nationalities, with the aim to identify the risk factors statistically more significant for the development of depression during pregnancy and in the postpartum period. In the meta-analysis of Robertson and colleagues, the authors analyzed the results of the more recent studies of nearly 10,000 additional subjects in relation to the findings of the meta-analyses (Robertson et al., 2004).

Depression or anxiety during pregnancy

Previous researches suggest that the presence of depression or anxiety during pregnancy is an important risk factor for depression in the postpartum period (Beck, 2001; Mauri et al., 2010; Robertson et al., 2004). Moreover, higher levels of anxiety during pregnancy predicted higher prevalence of postpartum depressive symptoms (Watson, Elliott, Rugg, & Brough, 1984).

Personal and family history of psychiatric illness

The average effect size of past history of psychiatric illness is one of the largest among the risk factors of postpartum depression. A personal history for psychiatric disorders, not just related to childbirth, lead to an increased risk for post-partum depression (Beck, 2001; Robertson et al., 2004). Although the investigation for psychiatric family history can be often methodologically problematic, the current evidence from large-scale studies suggests that having a positive family history for any psychiatric illness confers an increased risk for the development of postpartum depression, although the effect size is small (Johnstone, Boyce, Hickey, Morris-Yatees, & Harris, 2001). A family history

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of psychiatric illness during the lifespan has been observed as an important risk factor also for antenatal depression (Jeong et al., 2013; Lydsdottir et al., 2014).

A previous history of mental illness, in particular a history of anxiety and depression and a history of psychiatric treatment during the lifespan or during a previous pregnancy are well-established risk factors also for the development of antenatal anxiety and antenatal depression (Biaggi, Conroy, Pawlby, & Pariante, 2016). Many studies highlighted the role of history of previous anxiety or depression as the strongest risk factor for a new onset of maternal psychopathology during the antenatal period (Biaggi et al., 2016). Some studies found that past (Lee et al., 2007) or current (Marcus, Flynn, Blow, & Barry, 2003) use of alcohol have a significant correlation between antenatal anxiety and depression.

Life events

The relationship between stressful life events and depressive disorder is well established (Robertson et al., 2004). Bereavement, separation, divorce, job loss, moving home may represent stress factors that in subjects without a history of affective disorders can trigger the onset of depressive episodes. The pregnancy and the post-partum itself can be considered as important factors of stress. O'Hara and Swain (O'Hara, 1996) evaluated 15 studies, comprising data on over 1000 subjects, that had prospectively recorded data on life events. They found a strong–moderate relationship between experiencing a life event and developing perinatal depression. However, there was heterogeneity between studies in relation to the country where the study was conducted. For pregnancies that occur in a problematic social context the risk for the development of a depressive episode appears higher. Many studies have shown that adverse events in life and high perceived stress during pregnancy play an important role also in the onset of antenatal depression (Biaggi et al., 2016).

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Social support

Adequate support of partner, family members or friends in stressful life situations represents a protective factor against the development of perinatal depression (Brugha et al., 1998). Social support is a multidimensional concept. According to Robertson and colleagues (2004), there are different types of social support: informational support (during which they are given advice and guidance), instrumental support (practical help, material support) and emotional support (concerns and estimate). Studies have found a strong correlation between postpartum depression and insufficient emotional support and instrumental support during pregnancy (Beck, 2001; O'Hara, 1996). Also perceived social isolation or lack of social support during pregnancy was a strong risk factor for depressive symptoms in the postpartum period (Seguin, Potvin, St-Denis, & Loiselle, 1999). These findings suggest that women who do not receive good social support during pregnancy have an increased risk for the development of postpartum depression. However, consistent differences have been found between depressed women's perceptions of social support and the amount of support they objectively received (Logsdon, Birkimer, & Usui, 2000). These discrepancies could be due in part to the fact that depressed women tend to view everything more negatively, including the perception of the level of support they received. Lack of social support has also been strongly associated with an increased risk of antenatal anxiety and depression (Biaggi et al., 2016).

Marital relationship

Closely link to the findings on social support, several studies have reported an increased risk of postpartum depression in pregnant women who experienced marital problems (Beck, 2001; R. C. Kumar, 1997; O'Hara, 1996). Although it is difficult to establish a causal relationship between lack of support and the onset of depression, it is known that

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postpartum depression is frequently associated with an unsatisfactory relationship with the partner (Tamminen & Rasanen, 1990). Mothers with a satisfactory social support tend to perceive an adequate support also from their partners (Demyttenaere, Lenaerts, Nijs, & Van Assche, 1995). A problematic or dissatisfied relationship with the partner has been identified as a risk factor for the onset of anxiety and depression especially during pregnancy (Giardinelli et al., 2012).

Poor care-giving experience

The quality of the woman's relationship with her own parents is an important risk factor for antenatal psychopathology. For example, childhood abuse has been recognized as a clear risk factor for depression and anxiety specifically during pregnancy (Plant et al., 2013; Robertson-Blackmore et al., 2013). The absence of a good care-giving experience makes it more difficult for the mother to cope with distressing feelings and situations related to parenthood. The development of maternal identity involves the elaboration and integration of mental representations of the unborn child, of the woman as a mother, of non-maternal self-characteristics and of other significant relationships (Ammaniti and Trentini, 2009).In particular, one study (Jeong et al., 2013) highlighted the role of past experience of insufficient emotional support from the mother as an independent predictor of antenatal depression.

Psychological factors: neuroticism

Maternal personality characteristics such as neuroticism have been measured as risk factors for postpartum depression. The term neurotic, no longer used by the current classification systems, is commonly used in questionnaires that assess personality to indicate a condition of psychological stress characterized by tension, insecurity, anxiety, and low self-esteem. The neurotic disorders are usually viewed as ways of dealing with anxiety. Several studies have shown that this variable would represent a weak to

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moderate risk factor (O'Hara, 1996; Robertson et al., 2004). In a study by Johnstone and colleagues (Johnstone et al., 2001), women who were described as “being nervous”, “shy”, “self-conscious”, or a “worrier” through assessment tools were more likely to develop depression in the postpartum period. Similarly, women with negative cognitive styles as for example tendency to pessimism, anger, ruminations were more likely to develop postpartum depression (O'Hara, 1996).

Obstetric factors

Obstetric factors including pregnancy-related complications such as preeclampsia, hyperemesis, premature labor, as well as delivery-related complications, such as caesarean section, instrumental delivery, premature delivery, and excessive bleeding intrapartum have been examined as potential risk factors for postpartum depression (Robertson et al., 2004). Threat of miscarriage, abortion, or other gynaecological or obstetric complications, may expose the woman to high levels of stress (O'Hara, 1996). A recent study on more than 5000 women underlines the role of obstetric complications of previous pregnancies (premature births and post-term births, abortions) as risk factors for the development of depressive symptoms during pregnancy (Koleva, Stuart, O'Hara, & Bowman-Reif, 2011). Although caesarean delivery appear to be a weak predictor for post-partum depression, when the caesarean section takes place under conditions of urgency, the risk seems to become more significant (Boyce & Todd, 1992). Other studies related to caesarean section as a risk factor for postpartum depression have yielded mixed results. Fisher and colleagues (Fisher, Astbury, & Smith, 1997) reported that women who had a spontaneous delivery showed good levels of self-esteem and conditions during the later period of gestation; those for which it was necessary to plan a caesarean section showed reduced self-esteem and a lower mood, instead women who had planned a spontaneous delivery, but had then a caesarean section, reported

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intermediate scores. Some authors have reported a higher risk for postpartum depression during the first pregnancy compared to subsequent delivery (Yalom et al., 1968). Mixed findings have been reported regarding the relationship between unplanned or unwanted pregnancies and breastfeeding and postpartum depression (Robertson et al., 2004). In summary, the evidence suggests that obstetric factors make only a small but significant contribution to the development of postpartum depression. Some of the variables measured may not be truly independent but rather are influenced by extraneous variables. It should also be noted that an unplanned pregnancy merely reflects the circumstances in which the pregnancy occurred, and is not a measure of the woman’s feelings toward the fetus. Therefore, the results may be reflecting trends within the sample rather than an etiological relationship between postpartum depression and obstetric variables (Robertson et al., 2004). Women with current or past pregnancy/delivery complications, with a history of pregnancy loss and stillbirth have been found to be more likely to experience also antenatal depression, anxiety and pregnancy-specific anxiety symptoms (Biaggi, 2016).

Socioeconomic status

Socioeconomic deprivation indicators, such as unemployment, low income and low cultural level have always been considered risk factors for the development of mental disorders and especially for depression (Patel, Araya, de Lima, Ludermir, & Todd, 1999). Some studies suggest that these factors play a small but significant role in the development of depression in the postpartum (Robertson et al., 2004). The relationship between socio-economic factors and depression in the postpartum remain significant also in other countries and cultures (O'Hara, 1996; Patel et al., 1999).

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Effects of maternal psychopathology on child development

Maternal depression during pregnancy and in the postnatal period has been associated with the occurrence of a range of health and development problems in children (Suri, Lin, Cohen, & Altshuler, 2014). Depressed mothers during pregnancy have an increased risk of preterm birth, with possible adverse health outcomes of their child (Locke et al., 1997). Some studies highlighted a correlation between maternal depression during pregnancy and the risk of preterm birth, lower birth weight, smaller head circumference and lower Apgar scores (Uno H et al., 1990; Alves SE et al., 1997). Children of depressed mother showed less frontal brain activity in basal and after stimulation EEG recordings (Dawson, Klinger, Panagiotides, Hill, & Spieker, 1992). Dysregulation of the hypothalamic-pituitary-adrenal axis has been associated with depression. Depressed mothers may have increased blood levels of cortisol and catecholamines that could modify placental function by altering the uterine blood flow and cause uterine irritability (Glover, 1997). Some animal study have shown that stress during pregnancy can have effects in the off-springs; particularly, prenatal stress has been associated with an increased risk of neuronal death, abnormal development of foetal neuronal structures and dysfunction of the hypothalamic-pituitary-adrenal axis (Alves et al., 1997). Women who exhibit depression during pregnancy may have negative outcomes related to a reduction in the self care, reduction of appetite and a consequently lower increase in body weight (Teixeira, Fisk, & Glover, 1999). A recent review of published literature showed that untreated depression during pregnancy is associated with short-term neonatal effects, including increased distress after delivery, less than optimal orientation and motor activity, and disrupted sleep. Longer-term effects on neurobehavioral outcome have also been reported, including disruptive social behavior, depression, and changes in the period of sensitivity for language discrimination. Also antidepressant exposure during pregnancy has been associated with adverse short-term perinatal

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symptoms, including effects on autonomic and motor activity, habituation, and sleep. Longer-term studies of neurobehavioral outcomes of in utero antidepressant exposure suggest potential effects on gross motor function and language development but not cognition (Suri et al., 2014).

Depressions in the mother can double the risk of the child to suffer from depression himself or to have emotional–behavioural difficulties (Giallo, Cooklin, & Nicholson, 2014). Children of mothers with mental disorders appeared to be at risk of subsequent psychopathology and poor functioning in a range of developmental domains (Moehler et al., 2007). Moehler reported that even postnatal maternal depressive symptoms not reaching the level of clinical diagnosis and for which a specific treatment is not needed have an impact on child behavioral development (Moehler et al., 2007). Depressed mothers are often described as being passive, withdrawn, unresponsive or intrusive (Field, 1998, 2010). They also express more negative feelings towards their children

than non-depressed mothers (Reck et al., 2004). The infants of depressed mothers

showed lowest social engagement, less mature regulatory behaviors and more negative emotionality (Feldman et al., 2009). Moreover, the interaction through facial expressions and vocalizations is reduced in mothers who suffer from depression (Beck, 1996). This unsatisfactory early interaction has an impact on long-term development of the child (Beck, 1996). Because of the wide range of possible symptoms including in the diagnosis of postnatal depression, studies on the effects of postnatal depression on mother-infant interactions show significant variability. Researchers have identified distinct patterns of maternal responsiveness in the context of postnatal depression (Cohn, Matias, Tronick, Connell, & Lyons-Ruth, 1986). The main patterns that have been described belong to two groups: the first one refers to those mothers who appear remote and withdrawn, interacting little with their child, while the second one refers to the mothers that appear overly stimulating, intrusive, and even hostile in the contacts

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with their infants. A further group include depressed women who function well in their interactions with their babies (Williams & Carmichael, 1985). The hostile and intrusive behaviour that is characteristic of some depressed mothers, especially those who experience marked background adversity, may directly cause infant distress and emotional-behavioural dysregulation.

Other factors, such as the severity and chronicity of the disorder and the level of background adversity are also influential. Notably, even in the absence of depression, marked adversity increases the risk of mother-infant interaction problems, in all probability because the mother’s worries and preoccupations with her difficult circumstances interfere with her capacity to respond to her baby (Murray, Fiori-Cowley, Hooper, & Cooper, 1996). The wide range of problematic developmental outcomes for children of mothers who were postnatally depressed includes elevated rates on insecure attachment, behaviour problems in childhood, poorer cognitive functioning, and elevated rates of psychiatric disorders in adolescence. These poorer outcomes are more likely to occur in the cases in which mother’s depression is severe and chronic, as well in those with high levels of socio-economic adversity (Murray, Arteche, et al., 2010). Particularly in high risk samples, infants of depressed mothers are more likely than those of non-depressed mothers to show avoidant and distressed behaviour while interacting with their mother (Cohn et al., 1986). There is a significant association between the degree to which the mother’s behaviour is impaired and the extent of these signs of infant difficulty (Murray, Fiori-Cowley, et al., 1996).

Parent’s overall level of child-centred responsiveness, or contingency, during social interactions is of major importance for their child’s cognitive development (Eshel, Daelmans, de Mello, & Martines, 2006). It is a dimension of other’s communication, to which babies of even two months are sensitive. Experiences of a high degree of contingency in caregiver’s response appear to help fundamental learning processes in

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the infants (Dunham, Dunham, Hurshman, & Alexander, 1989). Low contingent responsiveness in the early postnatal month appeared, therefore, to set the infant on a trajectory of poorer cognitive functioning that persisted right through childhood. In the Cambridge longitudinal study, in fact, at 5 years follow-up, children whose mothers had shown a marked reduction in responsiveness in the postnatal period were found to continue on a trajectory of poor cognitive functioning (Murray, Hipwell, Hooper, Stein, & Cooper, 1996). The 1999 NICHD study found that in cases where interactions were particularly poor, with low levels of sensitive responsiveness, the risk for poor child cognitive outcome was substantial. In contrast, children whose mothers maintained good interactions, despite their depression, were protected from the potentially negative effects of the maternal disorder on cognitive functioning. In a clinical-based Australian sample, Milgrom and colleagues found that low maternal responsiveness at six months mediated the adverse effect of maternal depression on boy’s IQ at 42 months.

The way in which parents modulate their vocalizations when engaging with their baby appear particularly important for gaining and maintaining infant attention. Difficulties in depressed mothers’ interactions that concern infant attention regulation are also likely to contribute to poorer infant cognitive performance, since the infant’s ability to sustain attention is a particularly strong predictor of childhood IQ (Slater, 1995).

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THE MATERNAL ANTENATAL AND POSTNATAL

ATTACHMENT

Attachment is defined as the capacity to form selective and enduring bonds and represents one of the fundamental features of human experience (Bowlby, 1969). Since the publication of Bowlby's work The nature of the child's tie to his mother (1958), which introduced the principles of attachment theory, the research into attachment systems has become one of the main areas of interest in developmental psychology. Several studies in humans and animals have demonstrated the inborn propensity to form attachment as well as the physiological and behavioral correlates of bonding, the outcomes of secure and insecure attachment, and the factors associated with disturbances in parent-infant bonding. Most studies, in line with Bowlby's initial work, explored the development of child's bonding to the mother, while the maternal attachment was examined as being a facilitator of infant attachment (e.g. Ainsworth, Blehar, Waters, &Wall, 1978). Winnicott was perhaps one of the first author who point out the presence of a particular emotional state in new mothers, particularly characterized by an increased sensitivity, that soon after delivery becomes fully adapted to the identification and satisfaction of the infant’s physical and emotional needs. Research on the mother to infant attachment focused on the maternal emotional involvement to the child. Subsequently, literature provided some conceptual and experimental evidence suggesting that the emotional involvement with the infant start developing from early pregnancy. In particular, Cranley and Condon stated that the relationship with the child has an emotional dimension existing from the beginning of pregnancy that defined antenatal attachment.

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History of the construct of maternal-fetal and maternal-infant

attachment

History of postnatal attachment

In Bowlby’s attachment theory, human attachment has been conceptualized as a system of evolutionary behaviors that begin at birth and persist through adulthood, motivated by or toward fear, affection, exploration, and care-giving (Bowlby, 1958). Bowlby proposed the presence of a “care-giving system” which was an organized set of behavior to guarantee the proximity and protection to the child. When activated, the care-giving system ensures that “the infant remain close to the caregiver”, guaranteeing the survival of the child. The central feature of the care-giving system is “the provision of a secure base from which a child can make sorties into the outside world to which he can return”. The care-giving system, complementary and reciprocal to the child attachment system, ensures the child/species survival. Constant feed-back is observed between the care-giving system and the child attachment system, “a shared dyadic program between the parents and the child occurs as the behavior of the one is the complement of the other” (Bowlby, 1979/1982). The regulation of the dyadic attachment interactions between the mother and the infant was initially assumed to be solely biological. Bowlby hypothesized that the infant’s primary goal was to maintain a certain degree of physical proximity to the mother for survival. In fact, one of the main stepsin the development of attachment theory was Bowlby's link between human attachment and the empirical and theoretical framework of ethology (Bretherton, 1987; Hinde, 1974; Hofer, 1995b). Ethology has given a set of tools that are prerequisite for the building of attachment’s theory, that include the observation, assessment, and hierarchical categorization of behaviors emerging or intensifying during bonding. The ethological perspective implied that behaviors characterizing the attachment need to be interpreted in relation to survival and evolutionary adaptation. In mammals, survival depends on the maintenance

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of parent-infant proximity and consequently the concept of proximity became the basis of attachment theory. In his work “Attachment, Separation, and Loss” , Bowlby (1969, 1973, 1980) suggested that infant behavior should be understood in accordance to the degree of closeness or distance from the mother. The initial separation evokes protest and the intensification of attachment-related behavior; the loss (continuous distance) results in despair and the disappearance of the attachment complex. Only later, Bolwby’s attachment instance included also psychological goals on the part of the developing child and mother (Bowlby & Institute of Psycho-analysis (Great Britain), 1969), but he confirmed attachment to be an independent behavioral system and not necessarily determined by unconscious drives.

Mary Ainsworth, a Bowlby’s colleague, supposed the infant’s contribution to the attachment process to be more than biological, including his or her own affective appraisal of the mother’s behaviors (Ainsworth, 1978). The “Strange Situation2” laboratory testwas created by Ainsworth to scientifically capture for the first time the activation of attachment system behaviors between mother and child (Ainsworth MD,

2_{The Strange Situation is the standard laboratory assessment of attachment security in infancy.} In the procedure created by Mary Ainsworth the child is observed playing for twenty minutes while caregivers and strangers enter and leave the room in a series of eight episodes lasting approximately 3 minutes each. At the beginning the child is with his mother and is allowed to play and explore alone. A stranger enters the room, talks to the mother, and approaches the child while the mother leaves the room. After a short period, the mother comes back and reunites with the child. The mother and the stranger leaves, and the child is left to play alone. The stranger then comes back and attempts to interact with the child. The mother returns for a second reunion as the stranger leaves. Throughout the procedure, the child is observed on the presence of separation anxiety, stranger anxiety, the reunion behavior and play behavior. Ainsworth categorized the nature of the children's attachment into three groups: secure attachment, insecure avoidant, and insecure ambivalent attachment. Child having a secure attachment is able to freely explore when the mother is around, interacts with the stranger when the mother is present but doesn’t interact when she is absent, shows distress when the mother leaves, and is happy when the mother returns.

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1969). Authors took note of the mother’s responses to the infant at reunion, suggesting that the attachment system included influential maternal behaviors. Ainsworth and colleagues introduced the term “sensitivity” referring to “the maternal behaviors that revealed the mother’s degree of engagement with the emotional world of the infant” (Ainsworth, 1978). They found that mothers who showed sensitive caregiving behaviors were more able to match to baby’s signals with attentiveness, appropriately interpret and respond to the signals, and react promptly, with a latency that did not cause excessive frustration for the child. Maternal sensitivity positively correlated with a secure attachment style in infants.

The work of Donald Winnicott, a pediatrician and psychoanalyst, described the presence of a particular emotional state in recently delivered mothers (or even in late pregnancy) and labeled this psychological condition as the “Primary Maternal Preoccupation”, referring to the mother’s correct identification and immediate satisfaction of the infant’s physical and psychological needs (Winnicott, 1956) (p. 301– 302). Winnicott suggested this dissociated fugue-type psychological state to be necessary for healthy infant development and that mothers who did not experience primary maternal preoccupation would be “faced with the task of making up for what has been missed” (Winnicott, 1956). Winnicott adds to the behavioral repertoire also the mental dimensions of preoccupation, mental exclusivity, and anxiety. Winnicott maintained that although such high levels of obsessiveness would indicate a mental disorder at any other point in life, during bonding it is not only typical but critical to the formation of maternal attachment. This condition refers to the mother's obsessive-like involvement with thoughts of the baby, compulsive checking of the infant, ritualistic behaviors during feeding and care-giving, and an exclusive mental focus on the child. In fact, he probably was describing a temporary obsessive-compulsive anxiety phenomenon that develops late in pregnancy, peaks within a few days after delivery,

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and, in most women, slowly declines during the first few months postpartum (Leckman et al., 2004; Leckman et al., 1999). Winnicot later (1990) described four main holding task for the maternal role: to provide protection and care to the child, to take into account the child limitations and dependency status, to provide the necessary care for the child’s growth and development, and to love the child.

As proposed by Klaus and Kennell (1976), maternal-infant bonding is a specific an enduring bond between the mother and the child, which begin at childbirth for the majority of mothers. Childbrth is a critical period for the establishment of maternal bonding to the child. Normally postpartum bonding is established from the first contact with the newborn after delivery, to ensure the proximity of mother and child (M. K. Klaus, J., 1976). The contribution of Klaus and Kennell is characterized by three main observations: i) the existence of a critical and sensitive period in the moments following childbirth, ii) the importance of the mother’s hormonal equipment and of the infant’s presence, and iii) the feedback between the bio-behavioral equipment of both the mother and the infant. The early post-partum is an optimal/sensitive period for the establishment of post-partum bonding, depending on the adequacy of the hormonal system of the mother and the infant’s presence. In an important article published in 1972, the authors reported how mother who were allowed to more contact with their child after delivery showed more optimal maternal behavior: these mothers appeared more reluctant to leave their infants with someone else, usually stood and watched during the examination, showed greater soothing behaviors and engaged in significantly more eye-to-eye contact and fondling (M. H. Klaus et al., 1972). Therefore in the absence of post-partum contact, maternal-infant bonding could be compromised “affectional tie can be easily disturbed and may be permanently altered during the immediate post-partum” (M. K. Klaus, J., 1976). However the authors admitted that, although critical, the immediate post-partum period cannot be the unique moment in

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which mother-infant bonding is established. “it would be too dangerous for the preservation of the species if it could happen only in the initial post-partum” (M. H. K. Klaus, J.H.; Klaus, P.H., 1996). With regard to hormones, the author highlighted the role of oxytocin and stated that “the attachment felt between the mother and infant may be biochemically modulated through oxytocin” (M. Klaus, 1998).

Channi Kumar conceived “maternal attachment” as a gradual process of mother to infant affection, which is stimulated by the infant’s specific behavior and is largely influenced by the mother’s mental state. Kumar pointed out that the mother’s initial indifference to the infant is a frequent and normative response, and is distinct from the response which occurs in maternal bonding disorders (R. C. Kumar, 1997; Robson & Kumar, 1980). Kumar referred to the concept of maternal attachment as the mother’s affection toward the child, which is a gradual process, stimulated by specific behavior of the infant and varies according to the characteristics of the mother (R. C. Kumar, 1997). More recent approaches mentioned the role of biological, psychological and socio-cultural factors as determinants of mother-to-infant emotional involvement. Recent empirical evidence suggested that the representation of past experience of care may influence the way in which parents take care of the child (George, 2008).

Stern referred to the “motherhood constellation” as “a new and unique organization of mental life appropriate and adapted to the reality of having an infant to care for”. The motherhood constellation is progressively constructed throughout pregnancy and prepares the expectant mother to be a mother, and is based on a mother’s past relationship, especially with maternal figures, that are revisited during pregnancy. The motherhood constellation comes from the “reengagement with maternal figures and will determine a new set of actions tendencies, sensibilities, fantasies, fears and wishes. The expectant mother produces a representation of herself, as mother, and a representation of the infant (the imaginary baby), as her child” (Stern, 1995). The representation of

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self as mother and of the child as son/daughter are worked out throughout pregnancy, to prepare a mental space to receive the newborn and to perform all necessary actions for the care of the infant after the birth (Ammaniti, 1994; Stern, 1995).

Solomon and George extended the conceptions of Bowlby of the care-giving system and stated that the caregiving representational system has its roots in the construction of working models of self and other, in the context of attachment relationship during childhood, “but is a distinct model of relationship with its own developmental trajectory”(Solomon, 1996).

History of antenatal attachment

Psychoanalytic analyses explained prenatal attachment as a process in which the psychic energy of the woman during pregnancy was emotionally invested into the fetus (Benedek, 1959; Bibring GL, 1961). They hypothesized that the woman perceives the fetus as more human with the pregnancy progresses and feels the fetus both as an extension of self and as an independent object. This hypothesis was supported the clinical observation of mothers whose infants died during birth who exhibited an intense grief that was uninfluenced by whether or not the mothers had any physical contact with the babies after delivery (Kennell, Slyter, & Klaus, 1970).

The development of a formal theory of prenatal attachment began with Rubin who explored women’s attainment of the maternal role, concluding that the immediate bond in the early post-partum period between mother and neonate was a consequence of prenatal processes (Rubin, 1967, 1975). Although she did not use the term “attachment,” Rubin states: “by the end of the second trimester, the pregnant woman becomes so aware of the child within her and attaches so much value to him that she possesses something very dear, very important to her, something that gives her considerable pleasure and pride” (Rubin, 1975).

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Meanwhile, Lumley, a perinatal epidemiologist, found that first-time mothers, interviewed at various time points throughout the three trimesters of pregnancy, were able to imagine their babies in an increasingly human way over the passage of time. After the introduction of ultrasound during pregnancy, she began to examine the impact of a visual image of the fetus on maternal bonding (J. Lumley, 1990). She hypothesized that the early view of the fetus enhanced a mother’s ability to differentiate it as a “little person”. She carried out the first empirical longitudinal study of prenatal attachment that attempted to capture first-time parents’ attitudes of their fetus, through the use of simple tape-recorded interviews at five time points before and after childbirth. She conceptualized attachment as being an “established relationship with the fetus in imagination”, a mothers’ thought of the baby as a “real person” (J. M. Lumley, 1982). Lumley reported this phenomenon in 30% of the subjects in the first trimester, 63% in the second trimester, and in 92% in the third trimester of pregnancy. She interpreted delayed attachment as being related to unpleasant symptoms of pregnancy and lack of interest or support on the part of husbands.

Carrying on similar work in the United States, Leifer authored a monograph reporting findings from a study of nineteen first-time mothers on the psychological changes observed during the course of pregnancy (Leifer, 1977). She described pregnancy as a time of emotional disruption and rapid role change as well as a time of developmental maturation. Leifer also evaluated the role of personality into the psychological state of pregnancy, concluding that the degree of personality integration achieved during the first months of pregnancy could predict psychological growth throughout pregnancy and into early motherhood.

Cranley is considered the formal creator of the theoretical construct of antenatal attachment that defined as: “the extent to which women engage in behaviors that represent an affiliation and interaction with their unborn child” (Cranley, 1981b).

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Cranley proposed a multidimensional model composed of six aspects of maternal-fetal attachment (MFA) that she identified in her research.

The work of Müller underlined the role of also thoughts and fantasies in revealing the growing affiliation between mother and fetus, in order to complete Cranley’s construct of maternal fetal attachment that was so focused on behaviors (M. E. Muller, 1992; M. E. Muller & Ferketich, 1993). Müller redefined prenatal attachment as “the unique relationship that develops between a woman and her fetus. These feelings are not dependent on the feelings the woman has about herself as a pregnant person or her perception of herself as a mother”. Müller postulated that an expectant mother early experiences with her own mother or primary caregiver are relevant for the development of internal representations, which then influenced the way of attachment to friends, partner and family, and enabled a woman to adapt to pregnancy and attach to her fetus. Condon suggested that antenatal attachment could be described as a developing relationship in which the mother seeks “to know, to be with, to avoid separation or loss, to protect, and to identify and gratify the needs of her fetus”. He later defined antenatal attachment as “the emotional tie or bond which normally develops between the pregnant parent and her unborn infant” (J. T. Condon & Corkindale, 1997).

The most recent conceptualization of antenatal attachment has attempted to combine these behavioral, cognitive, and emotional approaches: “Prenatal attachment is an abstract concept, representing the affiliative relationship between a parent and fetus, which is potentially present before pregnancy, is related to cognitive and emotional abilities to conceptualize another human being, and develops within an ecological system”(Doan & . 2003 ).

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Assessment of the maternal antenatal and postnatal attachment

Instruments to evaluate maternal-foetal attachment

The first antenatal attachment scale, the Maternal Fetal Attachment Scale (MFAS), was based on the six aspects that Cranley postulated in her dissertation: differentiation of self from fetus, interaction with the fetus, attributing characteristics to the fetus, giving of self, role-taking, and nesting (Cranley, 1981a). The scale consisted of 37 items based on attachment-charged statements. After a pilot, due to a lack of statistical reliability, Cranley eliminated the nesting aspect; the resulting 24-item instrument consisted of five subscales and a global measure of maternal-fetal attachment. The MFAS is a quantitative measure efficient for cross-sectional studies in larger samples.

Müller found MFAS scale to gave inconclusive and often contradictory results (Muller, 1992; Muller & Ferketich, 1992). She thought that MFA could be viewed in a multidimensional fashion. Müller conducted a secondary analysis of the interviews with those participants, leading to the conclusion that only three of Cranley’s subscales corresponded with the categories generated by the interview data, while two others (Giving of Self and Interaction with the Fetus) did not correspond to available data. Müller theorized that Cranley’s items were not capturing certain emotional elements documented in the study of Mercer and colleagues (Mercer, Ferketich, May, DeJoseph, & Sollid, 1988). This analysis led to the development of the Prenatal Attachment Inventory (PAI) (M.E. Muller, 1990). The 29 items of this scale were designed to measure affectionate attachment or the personal relationship that the mother develops during pregnancy with her fetus. The construction contained no subscales, providing only a global score. Müller’s purpose was to stand as an adjunct measure to Cranley’s MFAS, with the broad goal of increasing agreement across studies (M. E. Muller, 1993).

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Some years later Siddiqui and colleagues evaluated Müller’s MFA construct (unidimensional and giving one global measure) with a sample of 171 Swedish women in their third trimester of pregnancy (A. H. Siddiqui, B.; Eisemann, M., 1999). Their analysis revealed an underlying dimensional structure with five identifiable factors representing recurrent themes that accounted for 53.9% of the variance: i) affection, ii) differentiation of self from fetus, iii) interaction, iv) sharing pleasure, and v) fantasy. They proposed that Müller’s scale supported a multidimensional construct of MFA. They suggested that this disagreement about the multidimensional validity of the scale could be related to the fact that Müller’s work had been conducted on women at various points in their pregnancy, while the Siddiqui and colleagues administered the PAI during a narrow window of the third trimester (between the 36th and 40th week of gestation).

The newest instrument on the maternal-fetal attachment was developed in Australia by John Condon (J. T. Condon, 1993). Condon’s purpose was to differentiate the attitude toward the fetus from the attitude toward the state of pregnancy and motherhood. The Maternal Antenatal Attachment Scale (MAAS) included 19 items focusing exclusively on thoughts and feelings about the baby and ignoring attitudes about the physical state of pregnancy or the maternal role. Two factors, “quality” and “intensity,” were generated. “Quality” described the affective experiences the mother reported, such as closeness/distance, tenderness/irritation, positive/negative, joyful/unpleasant anticipation, and a vivid/vague internalized representation of the fetus as a real person. “Intensity” referred to the amount of time she spent thinking about, talking to, dreaming about, or tactilely interacting with the fetus. Condon mapped these two factors as perpendicular continuums, forming four quadrants of MFA style: (1) strong/health attachment, (2) positive quality of attachment but low preoccupation due to distraction

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or avoidance, (3) uninvolved or ambivalently involved with low preoccupation, and (4) anxious, ambivalent or affectless preoccupation.

Of these described instruments, Cranley’s MFAS and Condon’s MAAS are the most commonly used measures. These multiple approaches to capture the attachment process increased attention to the construct of maternal antenatal attachment, with particular interest concerning its association with the mother’s early parenting experiences, cognitive capacity to develop an internal working model of her fetus, adult attachment style, level of social support, and the relationship with perinatal depression, anxiety, and postnatal attachment (Cannella, 2005). Measuring prenatal attachment may provide investigation of factors that are solely maternal, such as the mother’s own personality and attachment style.

Instruments to evaluate maternal-infant attachment

Several instruments have been developed with the aim to detect disorders in the early emotional bond between a mother and her newborn infant (J. T. Condon, Corkindale, C.J. , 1998; R. Kumar & Hipwell, 1996; Leifer, 1977; M. E. Muller, 1994; Nagata et al., 2000; Taylor, Atkins, Kumar, Adams, & Glover, 2005). The Maternal Postpartum Attachment Scale (MPAS: Condon and Corkindale 1998), the Postpartum Bonding Questionnaire (PBQ: Brockington et al. 2001) and the Mother-to-Infant Bonding Scale (MIBS: Taylor et al. 2005) are three of the most used self-report questionnaires to assess postnatal maternal bonding. Although these instruments aimed at describing the same disorder, they differ significantly in their contents.

The Maternal Postpartum Attachment Scale share the same theoretical framework with the Maternal Antenatal Attachment Scale (MAAS). Condon described the maternal attachment as the love of a mother for her infant. This model underpins several maternal dispositions towards the infant (pleasure in proximity, tolerance, need gratification and