Mother-to-infant bonding: determinants and impact on child development
Tichelman, Elke
DOI:
10.33612/diss.132367897
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Publication date: 2020
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Tichelman, E. (2020). Mother-to-infant bonding: determinants and impact on child development: Challenges for maternal health care. University of Groningen. https://doi.org/10.33612/diss.132367897
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Summary and general discussion
Aim of this dissertation
The overall aim of this dissertation was to further explore mechanisms of mother-to-infant bonding and to evaluate associations between mother-to-infant bonding and socio-emotional child development.Ultimately, the results may support maternal health care providers in addressing the transition to motherhood and mother-to-infant bonding in daily practice. In the first part of this chapter we will summarize our main findings. After this, we will discuss the interpretations of our findings in a specific order: first the etiological aspects, like correlates, determinants and the evaluation of the association between mother-to-infant bonding and socio-emotional child development. Secondly, the more practical perspective for the maternal health care providers like monitoring strategies and interventions in the light of general challenges in maternal health care in today’s society. Finally, we will present methodological considerations, implications of our findings and our conclusions.
Summary of main findings
In chapter two we reported the results of a systematic review investigating correlates of prenatal and postnatal mother-to-infant bonding quality. We performed a systematic search in MEDLINE, Embase, CINAHL, and PsychINFO through May 2018. The inclusion criteria and methods were stipulated in a protocol (PROSPERO CRD42016040183). Methodological quality was assessed using the National Institute of Health Quality Assessment Tool for Observational Cohort and Cross-sectional studies. Clinical and methodological heterogeneity were examined. In total 131 studies were included. Quality was fair for 20 studies, and poor for 111 studies. The quality of the studies on the various correlates varied. Most studies had a cross-sectional design which does not allow conclusions about temporal effects. Other limitations were underpowered sample sizes and not adjusting for possible confounders. Studies lacked mediation and moderation analyses when investigating possible mechanisms.
Among 123 correlates identified, three were consistently associated with mother-to-infant bonding quality: 1) duration of gestation at assessment was positively associated with prenatal bonding quality, 2) depressive symptoms were negatively associated with postnatal mother-to-infant bonding quality, and 3) mother-to-infant bonding quality earlier in pregnancy or postpartum was positively associated with mother-to-infant bonding quality later in time. Most child-related correlates of mother-to-infant bonding quality were examined in only a few studies
In chapter three we investigated the association between intrapartum synthetic oxytocin administration and child behavioral and emotional problems at the age of 45 to 60 months. In addition, this study examined the role of maternal mental health (postnatal depressive symptoms, postnatal anxiety and mother-to infant bonding) in this association.
Our study had a longitudinal study design. 1,528 women participated and filled out the Child Behavioural Checklist (CBCL). In total 607 women (40%) received intrapartum synthetic oxytocin. We used multivariable linear regression models to quantify the associations and calculated the unique variance explained by intrapartum synthetic oxytocin, postnatal depressive sympoms, postnatal anxiety and mother-to-infant bonding.
The results showed that intrapartum synthetic oxytocin was not associated with child behavioral and emotional problems ], nor with mother-to-infant bonding nor with postnatal anxiety. Intrapartum synthetic oxytocin was however statistically significantly, though weakly, associated with more postnatal depressive symptoms (β=0.17, p=0.02), therewith explaining a small amount of unique variance (0.6%). Maternal postnatal depressive symptoms, postnatal anxiety symptoms and mother-to-infant bonding were associated with child behavioral and emotional problems with an explained unique variance ranging from 2.0 to 3.7 percent.
In chapter four we described if and how primary care midwives adhere to the guideline of the Royal Dutch Organization of Midwives (KNOV) by addressing the transition to motherhood at the first prenatal booking visit and to what extent there was a difference in addressing transition to motherhood between nulliparous and multiparous women. This was a cross-sectional observational study of 126 video-recorded prenatal booking visits with 18 primary care midwives in the Netherlands. Five observers assessed dichotomously if midwives addressed seven topics of transition to motherhood according to the Dutch guideline Prenatal midwifery care from the Royal Dutch Organization of Midwives, and which of six communication techniques they used.
Overall, during every visit the transition of motherhood was addressed, the topics mother-to-infant bonding and support were addressed in 2% and 16% of the visits, respectively. Open questions were used in 6% of the prenatal booking visits. Nulliparous women brought up transition to motherhood on their own initiative more often than multiparous women (97% versus 84%).
We presented in chapter five the results of a systematic review of existing prenatal interventions to optimize mother-to-infant bonding and their effectiveness. We performed
a systematic search in Cinahl, Cochrane, Embase, MEDLINE, PsychINFO. Methodological quality and clinical heterogeneity were assessed using predefined criteria.
In total 22 studies were included. These studies concerned interventions that focus on improving mother-to-infant bonding by using group education (8 studies) or individual interventions including ultrasound (4 studies), prenatal screening (3studies), music (2 studies), fetal movement counting (2studies) and other individual interventions (3 studies). Within interventions with group education, training sessions aimed at bonding and attachment of mother and child were found to be effective in the majority of the studies. Yet, these studies had a high risk of bias. Out of the other interventions investigated, the majority of studies showed insufficient evidence for a conclusion on the effectiveness of the intervention and the risk of bias was usually high.
Chapter six described a prospective study with the aim of developing a multivariable
model to predict early in pregnancy suboptimal postnatal mother-to-infant bonding. In total, 634 participating women completed the Mother-to-Infant Bonding questionnaire. Suboptimal mother-to-infant bonding was defined as a score ≥ 4 on the Mother-to-Infant Bonding Scale. A broad range of prenatal predictors was considered. Multivariable logistic regression analysis was used to develop a prediction model. The explained variance and the discriminatory power of the final model were calculated. Finally, the multivariable model was transformed into an easy to use risk classification model for midwives.
The results showed us that the prevalence of mothers with suboptimal mother-to-infant bonding was 11%. Parity and adult attachment avoidance were the strongest independent predictors of suboptimal mother-to-infant bonding. Higher parity and higher levels of adult attachment avoidance were associated with an increased risk of suboptimal mother-to-infant bonding. The explained variance was 14% and the Area Under the Curve was 0.75. The explained variance was 14% and the Area Under the Curve was 0.75. The Hosmer and Lemeshow test had a p-value of 0.21. This resulted in a risk classification model.
Interpretations of the main findings
Etiological aspects
In the introductory chapter of this dissertation several knowledge gaps were described relevant to mother-to-infant bonding including gaps in the field of etiology. With our studies in chapter 2 and 3 we unraveled some parts of the mechanisms around mother-to-infant bonding. We will discuss both correlates, determinants and impact of mother-to-infant bonding.
We generated in chapter two more knowledge on correlates of mother-to infant bonding during the first 1,000 days of life (from conception to 2 years). Many correlates of mother-to-infant bonding quality were examined in only a few studies making firm inferences difficult. Findings support the theory that mother-to-infant bonding is a process that starts during pregnancy and continues postnatally (de Cock et al., 2016; Kinsey and Hupcey, 2013). Consequently, monitoring mother-to-infant bonding quality should already be considered during pregnancy. Interventions aimed at tackling depressive symptoms, which were found to be negatively associated with postnatal mother-to-infant bonding quality in the vast majority of studies have the potential to improve mother-to-infant bonding. Interventions aimed at decreasing depressive symptoms are currently becoming more important because of an increase in depressive symptomatology in pregnant women as is recently reported (Pop et al., 2019).
Aligned with chapter two, we generated in chapter three knowledge about a potential risk factor for less optimal mother-to-infant bonding and child development which was not previously investigated as such. We demonstrated that intrapartum synthetic oxytocin administration was not associated with child behavioral and emotional problems, mother-to-infant bonding and postnatal anxiety symptoms. However, intrapartum synthetic oxytocin administration was positively but weakly associated with postnatal depressive symptoms. The clinical relevance of this finding is negligible in the overall population, but unknown in a population with a high risk of a minor or major depression. It is precisely the population of pregnant women with depressive symptomatology that is increasing (Pop et al., 2019). Maternal healthcare providers can use this information to better inform women and help them to make choices in their birthing process. In women who already have a high risk of antenatal or postpartum depression, the initiation of intrapartum synthetic oxytocin medication should be carefully considered. We can also consider intensifying the monitoring of depressive symptoms in women who have a priori a high risk of postnatal depression and who received intrapartum synthetic oxytocin. Until now, health care providers have focussed mostly on the short-term consequences in the assessment of the safety of synthetic oxytocin (Simpson, 2011). However there is a need for information on longer term outcomes. Now they can use studies including ours showing that synthetic oxytocin does not affect behavioral and emotional problems in children. However we agree with other authors that there is still insufficient evidence to modify obstetric guidelines for the use of oxytocin, which state that synthetic oxytocin should only be used when clinically indicated (Lønfeldt et al., 2019).
The association between maternal postnatal depressive symptoms, anxiety and child behavioral and emotional problems has been reconfirmed in this dissertation. We have
stronger evidence that mother-to-infant bonding contributes to child behavioral and emotional problems. This means that we have more evidence that mother-to-infant bonding has impact on child behavioral and emotional problems. This finding is in line with the idea that during the first 1,000 days of life (from conception to 2 years) the foundation is laid for growing up healthy (College Perinatale Zorg, 2017; Ministerie van VWS, 2018). The finding that mother-to-infant bonding contributes to child behavioral and emotional problems is also in line with the recent review on the role of antenatal and postnatal maternal bonding in child development (Le Bas et al., 2020). This review focused on physical, psychological and social child development. The authors included nineteen articles. All mean effects were in the same direction with higher bonding contributing to higher attachment quality, lower colic rating, easier temperament and positive infant mood (Le Bas et al., 2020).
Some restraint with screening every woman for psychological complaints during pregnancy is recommended, as Brouwer indicates in her dissertation and Burger in a recent publication (Brouwer, 2019; Burger et al., 2019) as much is still unknown. For example, we do not yet have an appropriate intervention in pregnancy if we find psychological complaints, such as depression. We still don’t know what will be the best intervention for mother and child in case of depression (e.g. medication or Cognitive Behavioral Therapy).
Practical perspective for maternal health care providers
In the chapters four to six we generated knowledge about the more practical perspective for the maternal health care providers like monitoring strategies and interventions. In chapter four we concluded that professionals involved in maternal health care should consider addressing mother-to-infant bonding already early during pregnancy. We demonstrated that open ended questions are not used frequently to address transition to motherhood early in pregnancy. And the topics mother-to-infant bonding and support were not addressed frequently at the first prenatal booking visit. These results emphasize that maternal health care providers should ask more open questions early in pregnancy. Examples of open questions are beautifully presented in the Centering pregnancy implementation guide (Heberlein et al., 2016; Rising, 1998, 2004). Special attention for addressing mother-to-infant bonding in future research on the quality of prenatal care is recommended, because especially this topic is infrequently addressed during prenatal booking visits and because this topic is not included in the current Centering pregnancy program. Midwives who have not implemented the centering pregnancy program should pay extra attention to apply open questions by addressing transition to motherhood. The midwives should be aware to initiate addressing the transition to motherhood in multiparous women themselves. Maternal health care professionals should consider addressing mother-to-infant bonding
already early during pregnancy. In our opinion, the definition of early pregnancy in the context of mother-to-infant bonding is from 13 to 20 weeks of gestation. This is because after 13 weeks of gestation the risk of a miscarriage is very small. Before the 13th week of pregnancy, the risk of miscarriage is around ten percent and you can question whether it is already desirable to address mother-to-infant bonding in that early stage. Until now, addressing mother-to-infant bonding before 20 weeks of gestation has only been possible through open questions. Prenatal mother-to-infant bonding can be measured from approximately 20 to 24 weeks of gestation with self-report questionnaires (Cranley, 1981; van Bussel et al., 2010; Müller, 1993). We do not know if these questionnaires have enough discriminatory value in early pregnancy, because mother-to-infant bonding generally increases over the course of the pregnancy. In early pregnancy the values are expected to be much lower with less variation. A comprehensive psychometric evaluation in early pregnancy is therefore recommended to assess their measurement properties in terms of sensitivity to change, feasibility, reliability and construct validity.
If maternal health care professionals early in pregnancy will assess mother-to-infant bonding, we are able to monitor from halfway the pregnancy the mother-to-infant bonding and also monitor the mother-to-infant bonding early postpartum. For that purpose, the use of the relatively new Pre- and Postnatal Bonding Scale (PPBS) can be considered. The PPBS is currently the only questionnaire designed to measure both prenatal and postnatal to-infant bonding (Cuijlits et al., 2016). This can help to monitor the course of mother-to-infant bonding from pregnancy to the postpartum period. Yet, this questionnaire has so far only been used in research settings. The scale had a good factor structure, internal consistency (Cronbach alpha’s at 32 weeks’ gestation and at eight and 12 months postpartum were: 0.87, 0.80 and 0.79, respectively) and good construct validity (Cuijlits et al., 2016). Future research should further elucidate the validity and use of the PPBS in clinical practice. The ability to predict mother-to-infant bonding early in pregnancy was evaluated in chapter six. In chapter six it should be borne in mind that the predictors in our risk model are antecedents of the outcome. Predictors are not necessarily causal factors for suboptimal mother-to-infant bonding. This is because the data analysis aimed to identify variables that jointly had high predictive performance rather than to unravel the factors involved in the etiology of bonding problems (van Diepen et al., 2017). This study was aimed at the development of a model to predict suboptimal mother-to-infant bonding early in pregnancy. The model showed satisfactory performance. This study showed that higher parity and higher levels of adult attachment avoidance measured early in pregnancy were associated with an increased risk of suboptimal mother-to-infant bonding. The created prediction model should be optimized and externally validated.
The study described in chapter five yielded an overview of the effectiveness of the available prenatal interventions to optimize mother-to-infant bonding. This study showed that the scientific evidence for the effectiveness of prenatal interventions aimed at strengthening mother-to-infant bonding is generally limited. Interventions such as group education aimed at bonding and attachment, may offer treatment perspective for the future.
Challenges in maternal health care
This paragraph describes some personal thoughts about general challenges in maternal health care in today’s society in relation to the main findings of this dissertation.
Currently, maternal health care professionals have become increasingly aware of the fact that something is wrong with the way we as a society think about women in childbirth and maternity care. The increasing number of interventions in the childbirth process of all women, regardless of the risk status, is a fact (Olafsdottir et al., 2018). Childbirth has become medicalized, and paternalistic attitudes dominate our healthcare system, guidelines and regulations (MacKenzie Bryers and van Teijlingen, 2010; Miller et al., 2016; Scamell and Alaszewski, 2012). The risk-oriented medical model is dominant in maternal health care and influences women’s decision making and autonomy (Haines et al.,2012; Halfdansdottir et al.,2015). Cadée, the President of the International Confederation of Midwives, closed the 31st Triennial Congress by addressing midwives from around the world with her message that it is time to ‘humanize midwifery care – together’ (Cadée, 2017).
Reflecting on this, the use of a risk classification model and questionnaires on mother-to-infant bonding could be interpreted as a medical way to giving care with a focus on risks, quantity, interventions, professionals in charge and health as a result (MacKenzie Bryers and van Teijlingen, 2010). The disadvantage of this is that the risk approach is only a small part of good care. We face the challenge to see women as a whole. We could also interpret our findings in a humanized way. This is the more social way with focus on experience as an outcome in addition to health. Terms as women centered, woman in control, family oriented and women’s satisfaction are appropriate. In my opinion maternal health care professionals have a challenge to integrate the main findings of this dissertation into a more social way of health care. This means that they face the challenge to use questionnaires not as standard routine but to subtly weave the screening into care. They could start with asking more open questions like: “Tell about the feelings you experience towards the baby” or “What are your feelings about motherhood?” Only if there is a specific reason they could use questionnaires.
Care professionals and policymakers could ask themselves which preventive approach towards
suboptimal mother-to-infant bonding and a suboptimal transition to motherhood should be implemented in maternal mental health care. The guideline of the Royal Dutch Organization of Midwives (KNOV) recommended the primary preventive approach. The Dutch Health Council addressed in 2018 the preventive approach as well (Gezondheidsraad, 2018). The Dutch Health Council has provided an overview of interventions to prevent negative childhood experiences that demonstrably lead to misery in later life (such as child abuse, neglect). This overview did not include interventions to improve mother-to-infant bonding, but focused on interventions to improve parental sensitivity and attachment. The overview of systematic reviews and meta-analyses showed that a large number of interventions can be effective for a broad group of families, although the effects are not large on average. The effectiveness is larger if interventions are used if a child is six months or older than during pregnancy and the first months of life (Gezondheidsraad, 2018). Overall, the Council concludes that there is currently insufficient evidence to offer all parents in the general population interventions to improve parental sensitivity or attachment. And the Council concluded that it is important that the need for help from families is properly estimated, so to intervene at the right time (no under-treatment in combination with serious problems and no over-treatment with minor problems). The Health Council recommends risk stratification.
Meanwhile, the Dutch Ministry for Public Health, Wellbeing and Sports encourages and finances projects aiming at creating equal opportunities during the first 1,000 days of life. These projects have a high priority on the Dutch policy agenda and the ambition is that by 2022 every pregnant woman, child and family will receive preventive care for the best possible start (Ministerie van VWS, 2018). These projects are organized regionally. And in my opinion, these projects often do not integrate the best available evidence into practice. For example, they use a wide range of non-evaluated screening instruments. Whereas the introduction of screening instruments was often accompanied by research, there has been no research on the implementation of instruments in other regions, so that there is no insight into experiences with and effects of the instrument. Most screening instruments each seem to have their own specific focus on a limited number of aspects. Meanwhile, they also miss many aspects. It is a challenge to improve these projects by providing them with a sound scientific basis and we need to address this challenge urgently.
The main findings of this thesis can also be approached from a salutogenetic perspective. Salutogenesis is a medical approach focusing on factors that support human health and well-being, rather than on factors that cause disease (pathogenesis) (Magistretti et al., 2016; Smith et al., 2014). Some examples how to use the salutogenetic approach when interpreting the main findings are mentioned below. The first example is the opportunity for maternal health care providers to discuss with the mother the process of becoming a
mother already in pregnancy, e.g. by fantasizing together with the woman about her unborn child, by asking open ended questions to the mother during antenatal care, by stimulating her to talk about the name of the unborn baby and about her preparations to become a parent. In this approach, the maternal health care professional may emphasize, support and empower the skills and experienced positive emotions of the women. An approach not to be confused with the salutogenetic approach is the positive health approach where the formulation of health compromises the physical, mental and social domain. Positive health stimulates autonomy and self-management of the individual person (Huber et al., 2011). In the Netherlands, this approach is starting to be implemented in maternal health care nowadays (Verbeek, 2019). However, the value of the salutogenetic and the positive health approach is not yet investigated in combination with transition to motherhood, mother-to-infant bonding or child development.
Finally, the main findings can be approached from my own personal perspective. During my work as a midwife I assisted births and supported many women and their partners into the transition to parenthood. Especially, during my work at the Karolinska Hospital I learned extensively about the importance of mother-to-infant bonding and breastfeeding. My work experiences made me convinced that assisting mothers in their transition to parenthood is important, i.e. empowering women to feel they can manage their new role in life. In my opinion the transition to motherhood starts before birth and does not end after giving birth. Maternal health care professionals can encourage women who are at risk of suboptimal bonding to have themselves more intensely exposed to positive experiences (e.g. Centering pregnancy, ultrasounds in pregnancy, skin to skin contact) and to observe if there are any negative factors which can be avoided.
Methodological considerations
The studies in this dissertation were based on different data sources, each with their own methodological strengths and weaknesses as described in each chapter. Several methodological considerations pertaining to this dissertation should be mentioned: 1) level of evidence ; 2) longitudinal design; 3) heterogeneity of the population; 4) missing data; 5) the role of the partners. Each of these considerations will be briefly outlined below. A major strength of this dissertation is the level of evidence provided by our systematic reviews. The level of evidence of these studies is the highest achievable at this moment. Systematic reviews are on top of the pyramid of evidence. However, these systematic reviews had also limitations. The level of evidence varies between the different correlates
(chapter 2). Many correlates were examined in less than 10 studies and the quality of these studies was mainly poor which affects the validity and precision of the estimated correlation. Second, the large heterogeneity of the included studies might (partly) explain the inconsistent results and prevented us from drawing firm conclusions, let alone perform a meta-analysis. This means that we have to be cautious regarding the interpretation of the results despite the strong review methodology.
Another strength of this dissertation is related to the use of data from the Pregnancy, Anxiety and Depression (PAD) Study in both chapter three and chapter six (Meijer et al., 2013). Strengths of this data were the inclusion of a broad range of variables all selected for analyses based on literature and the longitudinal design of the study. The longitudinal design of the study, which started during pregnancy until 60 months after birth, contributes to the temporality of the associations found (Schunemann et al., 2011). Furthermore, the heterogeneity of this population caused by unselective population-based inclusion and a mixed recruitment setting of both primary and secondary care centers increased the generalizability of the results (Moons et al., 2009).
Nevertheless, the use of data from the (PAD) Study had some limitations. This study had 50% and 66% non-response on respectively the questionnaire on mother-to-infant bonding up to 24 months postpartum and on the questionnaire on child behavior 45-60 months postpartum. Many longitudinal cohort studies with a long follow up period are confronted with this problem. For example, Arguz et al. 2019 had 42% missing data on the outcome measured at 21 to 31 months postpartum and the Avon Longitudinal Study of Parents and Children (ALSPAC) had 65% missing data on its primary outcome (Eyre et al., 2019). Our response rate is considered low and results might be biased through selection processes. However we expect only little effect on the results of the study on the association between synthetic oxytocin and child behavioral and emotional problems because non-responders did not significantly differ from responders on child behavioral and emotional problems, on synthetic intrapartum oxytocin administration rates, and levels of postnatal depressive symptoms, postnatal anxiety and poor mother-to-infant bonding. We cannot rule out that selection bias might have led to an underestimation or overestiamation of the associations under study.
The fact that we focused on mother-to-infant bonding and transition to motherhood does not mean that partners have no role in parenting. Researchers pay more and more attention to to-infant bonding in terms of fetal-attachment prenatally, father-to-infant-bonding postnatally and transition to fatherhood. A longitudinal study showed
that both prenatal and postnatal maternal and paternal bonding were weakly to moderately correlated (de Cock et al., 2017). It could be possible that the bonding of the partner to the child could influence the mother-to-infant bonding and vice versa, especially, when the child is older and a bidirectional bond will establish (Ainsworth et al., 1978; Bowlby 1958).
Implications of the findings
Implications for practice and policy
• Maternal health care professionals should consider addressing mother-to-infant bonding already early during pregnancy from the 13th week of gestation (chapter 2) • Midwives could improve addressing transition to motherhood by using more open
ended questions (chapter 4)
• In pregnant women who have a risk of depression or are depressed, midwives should take the initiative to address the transition to motherhood (chapter 2 and 4)
• Midwives should focus on taking the initiative to address the transition to motherhood in multiparous women (chapter 4 and 6)
• In women who already have a high risk of postpartum depression or antenatal depression, the initiation of intrapartum synthetic oxytocin medication should be carefully considered (chapter 3)
Implications for research
• More high quality research on determinants of mother-to-infant bonding for which mixed results were found (e.g. social support and a desired pregnancy), and correlates that were examined in only a few studies, is needed in order to be able to address mother-to-infant bonding efficiently (chapter 2)
• A comprehensive psychometric evaluation in early pregnancy to assess the measurement properties of prenatal mother-to-infant bonding scales in terms of feasibility, reliability and construct validity, is needed
• More research is needed on the effectiveness of interventions aimed at the quality of mother-to-infant bonding. Especially, research on interventions such as group education aimed at bonding and attachment is needed (chapter 5)
• The risk classification model for suboptimal mother-to-infant bonding should be optimized and externally validated before use in daily practice. Future research should include a study into the additional value of non-included predictors, an external validation study combined with possible updating of the predictor weights, and finally a study on the impact and feasibility of the prediction model (chapter 6)
Conclusion
In summary, this dissertation contributed to the knowledge about mother-to-infant bonding. Our findings support the theory that mother-to-infant bonding is a process that starts during pregnancy and continues postnatally. We strengthened the evidence that mother-to-infant bonding contributes to prevention of child behavioral and emotional problems. According to our review of the literature, depressive symptoms are negatively associated with postnatal mother-to-infant bonding quality. We demonstrated that intrapartum synthetic oxytocin is not associated with child behavioral and emotional problems, mother-to-infant bonding and postnatal anxiety. Nevertheless, it is associated to a small extent with postnatal depressive symptoms. The clinical relevance of intrapartum synthetic oxytocin administration seems negligible in the general population as compared to other risk factors for postnatal depression. However, in a population with a high risk of a minor or major postpartum depression the clinical relevance in individual women is worthwhile investigating.
We recommend maternal health care providers to consider addressing mother-to-infant bonding already early during pregnancy. However there are no appropriate prenatal interventions yet to optimize mother-to-infant bonding or for women with psychological complaints like depression.
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