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The mother-infant bond: A systematic review of research that includes mothers’ subjective experience of the relationship

07 September 2018

Elizabeth Milne, Sally Johnson, Gill Waters and Neil Small explored mothers’ interpretations of their infants’ behaviour, and the impact of ‘mind-mindedness’, or treating a baby as an individual with a mind. 

Authors

Elizabeth Milne, Ph.D. Student at University of Bradford, Clinical Lead Perinatal Mental Health, Bradford District Care Trust
Dr Sally Johnson, Senior Lecturer in Psychology, University of Bradford
Dr Gillian M. Waters, Lecturer in Psychology, University of Bradford
And Professor Neil Small, Professor of Health Studies, University of Bradford

Corresponding author details:
Elizabeth (Lisa) Milne
Bradford District Foundation Care Trust
Specialist Mother and Baby Mental Health Team
Fieldhead House
2-8 St Martin’s Avenue
Bradford BD7 1LG
lisa.milne@bdct.nhs.uk
07891111156

A team of researchers at the University of Bradford reviewed research of the mother-infant relationship, focussing on mothers’ subjective experience of being in a relationship with their infant, in particularly the mothers’ understanding of their baby’s internal world.  They explored mothers’ interpretations of their infant’s behaviour, and the impact of ‘mind mindedness’ - that is a mother treating their infant as an individual with a mind.

Research summary

This study intends to answer the question: How do mothers describe the mother-infant relationship?

It is a systematic review of research, drawing out mothers’ subjective experience of being in a relationship with their infants, including their reports about companionship with their infants and the sense mothers make of their infant’s internal world, including verbatim quotes.

From an initial search of The Web of Science database resulting in 5,688 possible articles, twelve studies met inclusion criteria.

Findings from these studies were combined, and further analysis was carried out by re-exploring data extracts. Transcript extracts provided in each paper were re-explored.

Qualitative, quantitative and mixed methods of research were regarded as having equal value

A thematic analysis was used to create a narrative synthesis.


Abstract

Infants are social beings who need caregiving and companionship. Infants’ mental health is affected by their relationship with their caregiver. Mothers who make appropriate inferences about their infants’ internal worlds are associated with a variety of positive outcomes for their infants.

This article presents a systematic review of research on mothers’ subjective experience of being in a relationship with their infants. Twelve studies met inclusion criteria. Findings from these studies were combined, and further analysis was carried out by re-exploring data extracts.

This analysis indicated that the early post-natal period is often experienced as emotionally negative. Frequently, mothers did not perceive their infant as having an internal world. Inappropriate interpretations of the infant’s behaviour were related to negative experiences of the relationship. Appropriate maternal understanding of the infant appeared to alleviate stress, and a sense of mutuality with their infant was experienced as positive.

Implications for interventions and future research include the importance of health visitors helping mothers better understand their infants. This would support the mother-infant relationship, and benefit maternal mental health by decreasing maternal stress.

Keywords:

Mother-infant relationship, mind-mindedness, companionship, infant mental health.


Introduction

The infant is a sensitive, social being (Trevarthen, 2015). From birth, infants are capable of having complex and reciprocal interactions with others, that is “…the child is born with the motives to find and use the motives of others in ‘conversational’ negotiation of purposes, emotions, experiences and meaning” (Trevarthen, 1998). Neonates are sensitive to disturbances in communication (Nagy et al, 2017) and mothers and infants share mutual awareness, which includes sensitivity to one another’s signals and cues (Trevarthen, 1998). This mutual awareness enables a sense of emotional connection with mother and infant regulating one another’s awareness of each other (Siegal, 2015).

The majority of infant mental health issues are associated with relationship disturbances (Zeanah et al, 2000), therefore much research has investigated parental behaviours which benefit the parent-infant relationship. Mind-mindedness appears to be a powerful factor in the parent-infant relationship. The concept of mind-mindedness refers to the caregiver’s “proclivity to treat her infant as an individual with a mind, rather than merely as a creature with needs that must be satisfied” (Meins et al, 2001). In infancy, it predicts security of attachment with caregivers, and children’s later ability to infer mental states to self and others (Meins et al. 2013). It also predicts child outcomes in areas of cognition, linguistics and play (Meins 2013). Therefore, mind-mindedness, with its appropriate sense-making of the infant’s internal world, may enhance the parent’s ability to be a companion to their infant.

It has been argued that the infant needs both a caregiver and a companion (Trevarthen 2001). Whilst attachment theory has focused on how mothers’ respond to the infants’ distress, the importance of sharing positive moments may have been overlooked. Companionship is an inherent necessity for the infant, benefiting cognitive and social development including language, culture, memories, ideas, and additionally tying people together through affection, mutual joy and discovery (Reddy 2010). Joyous moments of connection between infant and caregiver help create the attachment - these are “supercharged” moments (Stern, 2004), shaping neurodevelopment and fostering good mental health (Schore, 2001).

Whilst the importance of the parent-infant relationship is emphasised in research and in policy, for example in the Department of Health’s Healthy Child Programme (Department of Health, 2009), it is not clear how mothers actually experience the relationship, how mothers see their infant’s internal world, or if they experience companionship with their infants.

Understanding mothers’ subjective experiences of their relationships with their infant should inform the development of interventions to support the mother-infant relationship. The review presented here explores how mothers subjectively experience their parent-infant relationship.

This review focused on studies of mother and infant. Although researchers have represented mothers’ voices in regards to their experience of motherhood (Smith, 1994), there is a dearth of research on the subjective experience of the mother-infant relationship. Therefore, this review focuses on studies that directly present the subjective experience of the mother and, to ensure the mother’s voice was present, also includes verbatim quotes.

Study aim

The question this systematic review intends to answer is:

How do mothers describe the mother-infant relationship?

This includes mothers’ reports about companionship with their infants and the sense mothers make of their infant’s internal world.


Method

Consistent with Centre for Reviews and Dissemination guidance (2008) a systematic approach was employed to review studies that reported on mothers’ subjective accounts of their experience of their mother-infant relationship. Qualitative, quantitative and mixed methods research were regarded as having equal value, as each provides different insights to reality and may, together, provide a fuller understanding than that provided by one methodological approach.

The Web of Science database was searched, resulting in 5,688 possible articles to include. Three were rejected due to not being in English. Twenty additional studies were included based on hand-searching literature. Studies were reviewed by title and abstract and excluded if they predominately focused on fathers, non-typical mothers, non-typical infants, breastfeeding or infants over 18 months. One-hundred-and-forty-one remained and were reviewed in full to see if they met the review criteria, 14 studies remained after this stage. Two were subsequently excluded for not meeting the required quality, a judgement informed by the Critical Appraisal Skills Programme (CASP) (2014) checklists. Twelve studies were left that met the criteria and were included in the synthesis (see Appendix 1: Table 1).

Narrative Synthesis

As the studies’ designs and focuses varied (see Appendix 1: Table 1), following Cochrane Guidance (Ryan, 2013) thematic analysis was used. This is an approach that examines and records patterns and themes within data. These patterns are then summarised in a narrative, a story about what the data tells us - termed a narrative synthesis. In an effort to consider different aspects of the data, transcript extracts from articles were re-explored.


Results

Initial themes were identified from the studies (see Diagram 1). Although some studies were rich in data regarding the parent-infant relationship, others were surprising limited. From the initial review, there was very little indication that mothers had a sense of companionship or mutuality in their relationship. Transcript extracts provided in each paper were re-explored. Line by line coding of the transcript extracts determined new themes and shifts in the importance given to them. Diagram 1 shows the synthesised themes, and these are discussed below.

 

Diagram 1: Themes at each stage of the process of analysis

Diagram 1: Themes at each stage of the process of analysis

Authors’ ways of seeing the relationship

The authors’ perceptions of what constitutes a parent-infant relationship had a significant impact on the interpretation of the data. For example, compare Zeanah et al.’s (1990) extracts:

Categorised as forming a relationship: I think it's a good relationship. Recently, I've thought that we're beginning to figure one another out. She still gets cranky at times when I breastfeed her, and I don't know what to make of that. In general, she responds well, though.

Categorised as immersed in the relationship: I feel it’s a very close relationship, partially because of nursing. It is very intimate – I feel a great deal of love for him. I feel, whatever you call it, the maternal instinct. I don't see myself going back to work fulltime as I had planned before. I don't want to share him with anyone else; I want to be his mother. I even felt a bit rivalrous when my own mother was here visiting for two weeks. Anyway, it's a wonderful feeling.

The former transcript extract provides a greater sense of infant as part of the relationship than the latter extract. The latter conveys a global sense of maternal affection towards the infant by the mother, but is less relationally rich. The authors of this study may have perceived parental affection as equating to a relationship, rather than a sense of both parent and infant as agentive, or of mutuality within the relationship. Authors tended to present the parent as active and the infant as reactive, even when the mother appeared to suggest a much more active infant (Bell et al. 2007).

The authors’ perceptions of the infant may have influenced the study design and analysis.

Absence

In two studies where data was collected from observing mothers’ interactions with others, rather than direct questioning, the absence of the mother-baby relationship was particularly notable (Olsson et al. 1998; Porter and Ispa 2013). Mothers and midwives appeared to omit consideration of the mother-infant relationship in their discussions (Olsson et al. 1998), although it was discussed with fathers. The authors did not acknowledge this difference.

Emotional time

Parents had a tendency to describe pleasure in the relationship by using global terms of loving the baby (Zeanah et al. 1990). Specific pleasures were: pride in motherhood, some caregiving tasks and successful meeting of the infant’s needs, holding and close contact with the baby (Blank et al, 1995; Horowitz and Damato, 1999; O'Brien and Lynch, 2011). Anger, frustration, confusion, anxiety, and stress were very common maternal experiences (Olsson et al, 1998; Horowitz and Damato, 1999; Bell et al, 2007; Limbo and Pridham, 2007; Murphy, 2007; O’Brien and Lynch, 2011; Parfitt and Ayers, 2012).

Perhaps reflecting the stress, anxiety and anger experienced by mothers, the need for moral and social support and social contact was identified by mothers ( Staneva and Wittkowski, 2013; Parfitt and Ayers, 2012; Blank et al, 1995). Mothers’ mothers (O'Brien and Lynch, 2011) and partners (Parfitt and Ayers, 2012; Bell et al, 2007; Delight et al, 1991) could be sources of support. However, the partner relationship could experience considerable transition and tension in the early weeks of parenthood (Bell et al, 2007).

Parents’ expectations

The studies demonstrated that mothers often had unrealistic expectations of infants. The wish for babies to be ‘easy, calm and well-behaved’ (Staneva and Wittkowski, 2013) was evident. Porter and Ispa (2013) point to parents wanting their children, who were under the age of three years, to eat and drink for themselves, wean themselves, try different food, sleep through the night, settle themselves, nap alone, tolerate being alone, sit, crawl, talk clearly, use the toilet, behave and not require comfort objects. They suggest their study demonstrates the tension between the desire for the child to be independent, and to be related to the parent, but the transcript extracts demonstrate little desire for relatedness.

Delight et al’s (1991) study presented a lack of parental knowledge regarding infant capacity, with over half of the parents agreeing antenatally that 'babies under six weeks old just feed, sleep, cry or fill their nappies' (Delight et al, 1991). Importantly, parents who had expected infant responsiveness antenatally were more likely to observe it postnatally. Multiparous mothers were no more likely to recognise their infants as responsive than primiparous mothers (Delight et al, 1991). It appears that parents see what they expect to see, and are veiled to their infant’s capacity if it is not consistent with their expectations.

The lack of perception of the infant’s internal experience is reinforced by Limbo and Pridham’s (2007) findings, where responsive attuned behaviour was expressed in less than half of the mothers.

Making sense – a developing process

There is a strong sense from some transcript extracts of parents learning to make sense of their infants (Zeanah et al, 1990; Blank et al, 1995; Bell et al, 2007; Limbo and Pridham, 2007; Murphy, 2007) and some mothers perceived the meaning making process being a shared one (Zeanah et al, 1990; Horowitz and Damato, 1999; Bell et al, 2007; Murphy, 2007).

Whilst there was evidence of some parents having appropriate perceptions of their infant’s internal world (Limbo and Pridham, 2007; Murphy, 2007; Parfitt and Ayers, 2012), it was common for the transcript extracts to demonstrate parents making non-attuned sense of their baby, with poor understanding of infant development (Zeanah et al., 1990; Murphy, 2007; Parfitt and Ayers, 2012). A strong theme was of parents perceiving the infant as coercive and manipulative, or taking the infant’s response as personal and negative feedback (Zeanah et al, 1990; Limbo and Pridham, 2007; Murphy, 2007; O'Brien and Lynch, 2011; Parfitt and Ayers, 2012; Porter and Ispa, 2013). For example:

I mean, just the other day she was really grumpy all day and I think it was because she knew I had to get my college essay done, you know.” (Murphy, 2007).

From the transcript extracts, lack of attuned understanding could be connected to the parent experiencing the child as frustrating or angering (Murphy, 2007) and parents perceiving themselves in a ‘battle’ with their child (Limbo and Pridham, 2007; Murphy, 2007). Parents’ emotional and mental states were related to the sense a parent makes of their infant; Parfitt and Ayers (2012) found that angry parents, or those who were depressed or anxious, were more likely to make comments suggesting a lack of understanding of their infants.

Meeting their baby’s needs could give mothers a sense of success (Blank et al, 1995; Bell et al, 2007; Murphy, 2007; Parfitt and Ayers, 2012). In contrast, when the baby was unhappy, struggling or wanted to do something different from the mother, mothers tended to interpret it personally, as if the infant was communicating how they felt about the mother (Blank et al, 1995; Bell et al, 2007; Murphy, 2007; Parfitt and Ayers, 2012; Porter and Ispa, 2013) leading to feelings of failure or anger (O’Brien and Lynch, 2011). However, from the transcript extracts, appropriate meaning making could dissipate frustration and personalisation of problems (Murphy, 2007) and maternal recognition of the infant’s internal world could result in the mother adjusting their behaviours to meet their infant’s needs (O'Brien and Lynch, 2011).

Mutuality

For some mothers, mutuality was something to look forward to as the infant got older (Blank et al, 1995; Horowitz and Damato, 1999). However, from the transcript extracts, some parents appeared to particularly value the sense of their infant’s agency and mutuality in their relationship. Parental warmth appeared to be conveyed in the expressions of parents who were describing a sense of mutuality (Zeanah et al, 1990; Delight et al, 1991; Bell et al, 2007; Parfitt and Ayers, 2012). The infant’s smile was identified as an opening to a reciprocal relationship for some parents (Zeanah et al, 1990); inviting shared pleasure in the relationship (Horowitz and Damato, 1999) and humanising the infant (Parfitt and Ayers, 2012).

However, most mothers did not convey a sense of mutuality or companionship in their relationships with their infants.

Responsivity is not synonymous with being in a relationship

Whilst the social development of the baby was found to be of particular importance to parents (Parfitt and Ayers, 2012), parents recognising that the infant was responsive did not equate to parents perceiving their infant as relationally active (Zeanah et al, 1990; Delight et al, 1991). Recognising that the infant responds to a stimulus does not require recognition of the internal world of the infant, or any sense of mutuality or companionship in the relationship.

Diverse views of the infant

Parents’ perception of their relationships and of their infants’ varied considerably within studies (Zeanah et al, 1990; Delight et al, 1991; Murphy, 2007; Parfitt and Ayers, 2012; Staneva and Wittkowski, 2013) and could change over time (Murphy, 2007). Babies could be described as:

“… not yet human” (Staneva and Wittkowski, 2013).

Or at times human, at times an object. For instance:

The baby is just like me, it is like a version of me…” (Parfitt and Ayers, 2012).

But there were also more extensive, complex descriptions of infants as active agents, with an internal world, in a mutual relationship. Having an appropriate sense of the child’s internal world appeared to be associated with a sense of mutuality and companionship.

Experts

There were examples of health visitors appearing to perpetuate the image of the infant as coercive and demanding (Murphy, 2007). Whilst experts may be perceived as influential, Murphy (2007) found that they could be resisted. Mothers who perceived their infants’ agency would, on occasion, describe challenging health visitors who did not.

Summary of Synthesis and Recommendations

This review demonstrated that the included studies authors’ perceptions of what constitutes a parent-infant relationship had a significant impact on the interpretation of their data. Researchers appeared to mainly portray infants as reacting, rather than as active and motivated, even when mothers were describing a more mutual relationship with their infant. Recognising that the infant is responsive (Zeanah et al, 1990) does not equate to mothers experiencing their infant as relational. Raising public awareness of infant’s relational capacities may be an area of focus for health visiting practice.

Companionship and/or connection was not often described by mothers. Where data were collated by means of observing mothers’ interactions with peers and professionals, any reference to the mother-infant relationship was largely absent. It may be mothers do not recognise their infants as relational or themselves as in a relationship with their infants.

This research suggests mothers:

  • often have inappropriate expectations of their infants’ behaviour;
  • demonstrated non-responsive and non-attuned behaviour with limited understanding of their infant’s internal world;

  • perceive their infants as coercive and demanding and/or their behaviour as personal and negative feedback. 

These ideas were associated with a sense of the child as frustrating or angering (Murphy, 2007) and being in conflict with the child. Experts, including health visitors, were also seen to perpetuate the story of the coercive and demanding baby (Murphy, 2007).

However, from the transcript extracts it appears that appropriate meaning making of the infant could dissipate frustration, and reduce the tendency to personalise the infant’s distressed behaviour as negative feedback about the mother (Murphy, 2007). Maternal recognition of the infant’s internal world could result in the mother adjusting their behaviours to meet their infant’s needs (O'Brien and Lynch, 2011). Pleasure from mutuality may be valuable, given how anxiety provoking and negative early parenthood experiences were found to be (Zeanah et al, 1990; Olsson et al, 1998; Horowitz and Damato, 1999; Bell et al, 2007; Parfitt and Ayers, 2012).

Recommendations for practice

It is apparent that there has been a lack of in-depth investigation into mothers’ experiences of their mother-infant relationships, and into how mothers perceive their infant’s relational capacity and internal worlds.  It appears that parents see what they expect to see and are veiled to their infant’s capacity if it is not consistent with their expectations (Delight et al, 1991). Based on this review, there are grounds to support interventions from health professionals, including health visitors, which seek to change the way mothers perceive their infants. Specifically:

  • In the light of mothers’ unrealistic behavioural expectations for their infants and maternal perceptions of infants as coercive and demanding, health visitors may be well placed to emphasise infants’ limited self-control and inability to manipulate their parents. This might be reinforced by providing information on the infants’ neurodevelopment.
  • Given the importance of companionship and connection for both mothers and infants, health visitors should focus on promoting the relational capacity of infants to mothers.
  • Health visitors’ interventions to improve mothers’ knowledge of child development at every contact may assist mothers in making more appropriate, and thus stress reducing, inferences about their child and invite mind-mindedness.

Conclusion

If Health Visitors are to support the transition to parenthood and the parent-infant relationship consistent with the Healthy Child Programme, and as parents’ have been found to perceive what they expect to perceive, interventions aimed at supporting mothers to make appropriate meaning of their baby’s minds may be valuable. Such interventions have the potential to alleviate stress, facilitate sensitive, attuned parenting, and enable a sense of companionship. Research should focus on how to make these conversations effective and practicable.

Limitations

This review was limited to one database. Whilst the database selected was chosen due to its breadth of papers, further review should include a greater range of databases. Re-exploring transcript extracts can be problematic – they are just snippets of data and recourse to full transcripts would be preferable. However, the process of re-exploring transcript extracts did enable different perspectives on the data to begin to be considered, particularly in regards to how the parent makes sense of their child, and the impact of this and experiences of mutuality. It enhanced the synthesis by identifying how researchers’ dispositions can influence interpretation.


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Appendix 1:

Table 1: Studies included in synthesis

Study and location of study

Participants

Age of child

 

Race or ethnicity information

 

Demographics

Aim of study

Method of data collection and analysis

Porter and Ispa (2013)

 USA

 

N=112

< 3 yrs

Unknown

Unknown

parents’ concerns in regards to childrearing.

 

 

Online message board postings

Content analysis.

Staneva and Wittkowski (2013) Bulgaria

N= 10 mothers

<18mths

Bulgarian

Educated

maternal expectations and beliefs about motherhood

Semi-structured interview

Length:

33 mins on average

 

Emergent Thematic

Analysis

Parfitt and Ayers (2012)

UK

 

N=85

4-8 mths

Caucasian 82%

Educated

mothers’ and fathers’ description of their baby, their role, their relationship with their baby; impact of mental health issues and anger

Semi-structured Interview (BIMMH, 5th ed.; Brockington, Chandra et al., 2006)

Length:

1hr 45

 

Themes emergent to make coding manual.

Quantitative analysis on content.

O'Brien and Lynch (2011) Ireland

 

N= 6

:

3-11 mths

Mixed:

Irish, Spanish, Czechs

Mainly professional

the nature of tactile interaction between parent and baby.

Semi structured interviews (no details of length or probes).

Emergent thematic analysis

Bell et al. (2007)

Canada (French)

 

N=18 mothers and 18 fathers

1-16 weeks

Caucasian, French speaking

Mean level of education -

14 years

interrelatedness of mother-infant and father-infant relationships over the first 4 months.

Interviewed across 3 time periods – 1, 6 and 16 weeks post-partum. (PIRI; Bell et al. 2000 cited in Bell et al. 2007) guided the interviews.

 

Grounded theory

Limbo and Pridham (2007)

USA

 

N= 29

2wk-12mth

Mixed

Mixed

mothers’ understanding of their infants

Semi-structured interviews based on real and hypothetical caregiving situations

Length:  1 hr

Analysis: Thematic analysis - predefined categories. Responses scored on an ordinal scale.

Murphy (2007)

UK

 

N= 36

:2 mthsand 2 yrs

Mainly Caucasian

Mainly middle class

how first-time mothers constituted childhood, in particular their own children.

Repeated semi- structured interviews focused on feeding

Length: 1-2 hr

Emergent thematic analysis

from sample created a priori categories.

Social construction and discourse analysis

 

Horowitz and Damato (1999)

USA

 

N=95

6 weeks

 

Diverse

Diverse

mothers’ perceptions of postpartum stress and satisfaction.

A number of written questionnaire

 Content analysis quantitative and qualitative analysis

Olsson et al. (1998)

Sweden

 

N=5 mothers and 3 fathers

 

Antenatal to 10-14 weeks

Swedish

not defined

conversations and meaning of parenthood from discussions between parents and midwives.

 

Videos of appointment between parent and midwife

10-60 minutes

8-16 visits each.

Content analysis and phenomenological hermeneutic analysis

Blank et al. (1995)

USA

 

N= 30

first day of birth

Mainly Caucasian

middle class

perception of the interpersonal factors that affected their responsivity to their infant.

 

Semi- structured interviews Interview

Length: 1.5 hrs using The Sullivan (Perry & Gawel, 1953 cited in Blank et al. 1995) tenderness theorem informed the generation of interview questions and the thematic analysis

Delight et al. (1991) UK

 

N= 416 mothers and 242 partners 278 families re-engaged

Ante and 3-4 mth

Not identified

Diverse

parents understanding of their infant’s responsiveness, fathers and mothers differences, impact of previous experience and learning from their babies.

Written questionnaires

Content analysis and comparative analysis

Zeanah et al. (1990)

USA

 

N= 35 as 3 excluded

not detailed in paper

not detailed in paper

middle class

Women’s perception of their infants’ personality, concept of their relationship with their baby and first feelings of love for their child. 

Semi-structured interviews with standard and individualised responsive probes. Content analysis.

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