Infant Behavior and Development 72 (2023) 101871

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Infant Behavior and Development

journal homepage: www.elsevier.com/locate/inbede

Maternal-infant bonding and partner support during pregnancy

and postpartum: Associations with early child
social-emotional development
Noor de Waal *, 1, Myrthe G.B.M. Boekhorst , Ivan Nyklíček , Victor J.M. Pop
Center of Research on Psychological disorders and Somatic diseases (CoRPS), Department of Medical and Clinical Psychology, Tilburg School of
Social and Behavioral Sciences, Tilburg University, Tilburg, the Netherlands

A R T I C L E I N F O A B S T R A C T

Keywords: The first 1000 days after conception are considered critical for healthy development and well-
Maternal-infant bonding being throughout life. Fundamental to health practices during pregnancy and positive
Partner support parenting after birth is the development of maternal-infant bonding. Previous research has
Pregnancy
demonstrated the importance of having an involved partner during pregnancy and in parenting
Postpartum
Child
for optimal maternal-infant bonding. The current study examined maternal-infant bonding and
Social-emotional development partner support during pregnancy and the postpartum period, and their associations with early
child social-emotional development. A total of 227 women completed the Pre- and Postnatal
Bonding Scale (PPBS) and Tilburg Pregnancy Distress Scale (TPDS) during pregnancy (32 weeks
of gestation) and at 8 months postpartum, assessing maternal-infant bonding and partner support.
Additionally, a questionnaire on social-emotional behavior of the Bayley Scales of Infant and
Toddler Development was administered to mothers to measure child development at 2 years of
age. Path analyses revealed an indirect positive effect of prenatal maternal-infant bonding on
child social-emotional development through postnatal maternal-infant bonding, as well as
mediating effects of pre- and postnatal maternal-infant bonding on the association between pre-
and postnatal partner support and child social-emotional development. Our findings support the
notion that an emotional connection from mother to child originates in pregnancy and that
experiencing positive feelings towards the fetus promotes positive maternal-infant bonding after
birth and social-emotional capacities of the child. Additionally, having a supportive partner
during pregnancy and postpartum, might be essential for the development of optimal maternal-
infant bonding.

The first 1000 days after conception are considered critical for healthy development and well-being throughout life (Berg, 2016). In
utero experiences and the quality of caregiving that is provided after birth, shape the way a child grows, learns, and thrives. For
example, elevated levels of distress during pregnancy have been associated with emotional and behavioral problems in the offspring
(Graignic-Philippe et al., 2014), as have mothers’ insensitive parenting behaviors in early childhood (i.e., inadequate or late responses
to infant signals; Behrendt et al., 2019). Fundamental to health practices during pregnancy (e.g., a sufficient amount of sleep,

* Correspondence to: Tilburg University, Department of Medical and Clinical Psychology, Room T417, Warandelaan 2, 5037 AB Tilburg, the
Netherlands.
E-mail address: [email protected] (N. de Waal).
1
ORCID: 0000-0002-2287-8426

https://doi.org/10.1016/j.infbeh.2023.101871
Received 10 June 2022; Received in revised form 18 July 2023; Accepted 30 July 2023
Available online 4 August 2023
0163-6383/© 2023 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
N. de Waal et al. Infant Behavior and Development 72 (2023) 101871

refraining from harmful substances) and positive parenting after birth is the development of maternal-infant bonding (Lindgren, 2001;
Medina et al., 2021), defined as the emotional tie that mothers feel towards their infant (Bicking Kinsey & Hupcey, 2013).
Maternal-infant bonding originates in pregnancy and evolves with gestation when fetal movements increase (Cannella, 2005;
Guney & Ucar, 2019; Tichelman et al., 2019). The strength of prenatal bonding has been shown to be a robust predictor of bonding
quality in early childhood (e.g., De Cock et al., 2016; De Cock et al., 2017; Le Bas et al., 2021; Tichelman et al., 2019). Previous
research has associated postnatal bonding quality with early child social-emotional capacities. For example, Mason et al. (2011) found
that stronger feelings of bonding in mothers at 2 months postpartum predicted better social-emotional development in their children at
6 months of age. Moreover, better maternal-infant bonding 6–8 months postpartum has been associated with fewer social-emotional
and behavior problems (e.g., negative emotionality, withdrawal), as well as more social-emotional competencies (e.g., empathy,
prosocial behavior) in 1-year-old children (Behrendt et al., 2019).
Although studies have emphasized the important implications of prenatal maternal-infant bonding for parenting competencies
(Bicking Kinsey & Hupcey, 2013), research on associations with child social-emotional development is scarce. Le Bas et al. (2021)
found positive correlations between bonding during each trimester of pregnancy and child social-emotional development at 12 months
postpartum. Yet, for the main analyses, this study focused specifically on the unique contribution of postnatal bonding, as a previous
meta-analysis showed stronger associations with infant development compared to mothers’ prenatal bonding quality (Le Bas et al.,
2020). In addition, meta-analytic research associated stronger prenatal bonding with an easier overall temperament and positive infant
mood (Le Bas et al., 2020). A systematic review found similar results in some of the studies included, with associations between
prenatal bonding and several temperamental dimensions (e.g., adaptability, intensity), but insignificant relations in other studies
(Branjerdporn et al., 2017). It should be noted though that the number of studies that were included in this review were limited, and
that some were of poor quality. Moreover, social-emotional development was not assessed in these studies. That is unfortunate
because, despite being related to one another (Salley et al., 2013; Sanson, 2004), temperament and social-emotional development are
distinct constructs (Liew, 2012; Sanson, 2004). The relatively small number of studies on prenatal bonding fail to provide a clear
picture on its potentially unique effect on social-emotional development, as well as the potential mediating role of postnatal bonding in
this association.
Literature has identified a variety of risk and protective factors for optimal maternal-infant bonding. For example, multiparity and
mental health problems (e.g., depression) were found to have adverse effects on the quality of bonding, whereas an intended preg­
nancy and social support were associated with a stronger bond between mother and child (McNamara et al., 2019). Previous studies
have also demonstrated the importance of having an involved partner during pregnancy and in parenting for the development of
maternal-infant bonding. For example, women living without a partner and women who did not feel supported by their partner during
pregnancy, experienced lower levels of bonding towards their fetus (da Rosa et al., 2021). Furthermore, mothers who were charac­
terized as having a strong bond with their child at 6 and 24 months postnatally reported higher levels of partner support (De Cock et al.,
2016). We previously demonstrated that partner support was one of the most important protective factors of maternal-infant bonding,
both during pregnancy and in the postnatal period (Cuijlits et al., 2019).
Prenatal partner support has been associated with a variety of other positive outcomes, such as maternal health behaviors during
pregnancy (e.g., less likely to drink alcohol; Cohen et al., 2016) and less maternal and infant distress after birth (Stapleton et al., 2012).
To our knowledge, no studies have examined the relation between prenatal partner support and child social-emotional development.
However, fathers’ involvement in pregnancy has been positively associated with the paternal share in caregiving (Zvara et al., 2013),
which has been studied in relation to child social-emotional development. Children who described their father as more supportive, also
reported a greater sense of competence and social acceptance at 6 years of age (Dubowitz et al., 2001). Moreover, Dubeau et al. (2012)
found in a rather small sample, that fathers who placed more emphasis on play interactions and spent more time on household tasks
including childcare, more often had children who displayed fewer internalizing problems and more prosocial behavior at age 4.
Another study, including a larger sample, found a positive effect of father involvement on peer relations in 7-year-olds, but no effects at
younger ages (Flouri et al., 2016). Regarding pregnancy and the first years of life, little is known about the relation between partner
support and child social-emotional capacities, or about the potential mechanisms that would explain such an association.
The current study examined maternal-infant bonding and partner support during the pre- and postnatal period, as well as their
associations with early child social-emotional development. Our hypothesis was that maternal-infant bonding during pregnancy and in
the postpartum period would be positively associated with social-emotional development of children at 2 years of age, and that
postnatal bonding would partially mediate the association between prenatal bonding and child social-emotional development.
Furthermore, we hypothesized positive associations between pre- and postnatal partner support and child social-emotional devel­
opment, either directly or mediated by maternal-infant bonding.

1. Method

1.1. Participants

The current study included a subsample of women who participated in the Holistic Approach to Pregnancy and the first Postpartum
Year (HAPPY) study, a large longitudinal prospective cohort study for which the protocol has been described previously (Truijens
et al., 2014). Pregnant women that were eligible for participation (i.e., Dutch speaking, Caucasian or third generation of other ethnic
groups) were recruited via community midwife practices. Exclusion criteria included multiple pregnancies (or higher order preg­
nancies), the existence of an endocrine disorder, severe psychiatric disorder (schizophrenia, borderline personality disorder, or bipolar
disorder), HIV, drug or alcohol addiction problems, or any other disease resulting in treatment with drugs that are potentially adverse

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for the fetus. During their participation, women (n = 2269) were followed throughout pregnancy and in the first year postpartum. Only
participants who were included between October 2013 and August 2014 received a questionnaire on maternal-infant bonding during
pregnancy (n = 1163) of whom data were complete for 1050 women. Of those women, 793 also completed the questionnaire in the
postpartum period. After completion of the cohort study, a subsample of 828 women was invited to participate in a follow up study
(selected based on [1] elevated levels of depressive symptoms, [2] suboptimal thyroid function or thyroid dysfunction, and [3] healthy
controls). A total of 485 women (59%) consented to participate. For the purpose of this study, only the participants were included that
completed pre- and postnatal measures on maternal-infant bonding, as well as child social-emotional development at follow up (n =
239). Additionally, participants had to be married or co-habiting and information on partner support during pregnancy and post­
partum had to be complete, resulting in a sample size of 227 participants (see Fig. 1 for an overview of enrollment). All participants
gave informed consent for the cohort study and its follow up study.

Fig. 1. Enrollment of participants. Note. PPBS = Pre- and Postnatal Bonding Scale.

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1.2. Procedures

Data for the original cohort study were collected between January 2013 and September 2014. Participants received questionnaires
via postal mail or email around 32 weeks of gestation and 8 months postpartum, assessing mother-to-infant bonding and partner
support. Although not examined for the questionnaires that were used in the present study, previous research demonstrated that results
for online and paper-and-pencil administration were comparable, both for self-rated (Luce et al., 2007) and parent-rated question­
naires (Bjornsdotter et al., 2013). Follow up data on child social-emotional development were collected between December 2016 and
June 2018, when the child was approximately 2 years of age. Once more, women completed questionnaires that were sent by postal
mail or were completed online. The study was approved by the Ethical Board of Tilburg University and has been evaluated by the
Medical Ethical Committee of the Máxima Medical Centre Veldhoven. The follow up study was approved by the Medical Ethics
Committee of the Máxima Medical Centre (protocol number NL54558.015.15). The study has been carried out in accordance with the
Code of Ethics of the World Medical Association (Declaration of Helsinki).

1.3. Measures

1.3.1. Mother-to-infant bonding

Mother-to-infant bonding was measured with the Pre- and Postnatal Bonding Scale (PPBS), a self-rated questionnaire that was
developed to assess maternal bonding during pregnancy and postpartum (Cuijlits et al., 2016). The PPBS holds an advantage over other
measures that assess either prenatal or postnatal maternal-infant bonding (Wittkowski et al., 2020), and are therefore not well
comparable and do not enable making a reliable assessment of bonding over time from pregnancy to postpartum (Cuijlits et al., 2016).
In addition, the PPBS specifically focuses on the affectionate domain. Positive feelings and emotions towards the child generally arise
during pregnancy (e.g., Tichelman et al., 2019) and, therefore, do not necessarily require a response from the child. Although
interacting with the child after birth may enhance feelings of bonding (Cuijlits et al., 2016), parental affections and feelings of love is
what defines bonding (Brandon et al., 2009), rather than parental behaviors that may or may not be associated with feelings of
bonding. Finally, the PPBS is a short questionnaire with a user-friendly set-up (Cuijlits et al., 2016). Only positively worded items are
included to prevent socially desirable answers and since previous research demonstrated that especially low scores on positive feelings
reflected poor bonding or a disorganized relationship with the child (Brockington et al., 2006). For prenatal and postnatal adminis­
tration, the PPBS demonstrated good psychometric properties and construct validity in a sample of 1050 pregnant women (Cuijlits
et al., 2016). Moreover, the PPBS has previously been used in various other studies (e.g., Kommers et al., 2017) and a systematic review
on parent-report measures of bonding indicated a sufficient structural validity and internal consistency (Wittkowski et al., 2020). The
questionnaire consists of five items that describe positive feelings of bonding (e.g., “Loving”, “Happy”). Women are asked whether
these feelings reflect their own feelings towards their fetus or infant over the last four weeks on a 4-point Likert scale (0 = not at all, 1 =
hardly, 2 = much, 3 = very much). For analyses, total scores were used that ranged from 0 to 15 with higher scores reflecting more
positive mother-to-infant bonding. In the current study, reliability was good with α = 0.86 and 0.78 for prenatal (32 weeks of preg­
nancy) and postnatal (8 months postpartum) administration, respectively.

1.3.2. Partner support

Partner support during pregnancy (32 weeks) was assessed using the partner involvement subscale of the Tilburg Pregnancy
Distress Scale (TPDS; Pop et al., 2011). The TPDS has been found reliable and valid for administration during pregnancy, with good
internal consistency for the subscale partner involvement (Boekhorst et al., 2020). To measure postnatal partner support (8 months
postpartum), the Tilburg Postnatal Distress Scale (TPDS-2) was used. Items of the TPDS-2 were derived from the TPDS and assess
partner support in the postpartum period. The TPDS-2 demonstrated good reliability in one of our previous studies using a larger
subsample (Cuijlits et al., 2019). By means of five items, mothers are asked to indicate the extent in which they feel emotionally
supported by their partner during pregnancy or in parenting (e.g., “The pregnancy/birth of the baby brought me and my partner closer
together” and “I feel supported by my partner”). Items are answered on a 4-point (prenatal administration) or 5-point Likert scale
(postnatal administration) ranging from 0 = very much to 3 or 4 = not at all, resulting in a subscale score between 0 and 15–20. For
analyses, all items were reversed so that higher scores indicate more partner support. In the current study, internal consistency of the
subscale partner support of the TPDS and TPDS-2 was good (α = 0.78 and 0.83 for prenatal and postnatal administration, respectively).

1.3.3. Child social-emotional development

The parent-rated social-emotional questionnaire of the Bayley Scales of Infant and Toddler Development – Third Edition – NL
(Bayley-III-NL; Van Baar et al., 2014) was used to assess child social-emotional development. The scale was designed to assess
social-emotional milestones in children up to 42 months of age. Rather than measuring isolated skills or competencies, the scale gives
rise to a broad representation of social-emotional behavior and accomplishments. The questionnaire, to be completed by the mother,
has previously been validated and found reliable in a sample of 1845 Dutch mothers (Van Baar et al., 2014). Items assess different
aspects of social-emotional development (e.g., self-regulation, interest in the world) by means of six answer categories (0 = don’t
know, 1 = never, 2 = sometimes, 3 = half of the time, 4 = often, 5 = always). Examples of items are “You can help your child calm
down when that is necessary” and “Looks at interesting things like faces or toys”. Total scores are converted into standardized index
scores which range from 40 to 160, with higher scores indicating better social-emotional development of the child. Reliability of the
questionnaire in the current study was excellent (α = 0.96).

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1.3.4. Covariates
Based on previous research that associated demographic factors, obstetric outcomes, and maternal mental health during pregnancy
to the current study’s variables (e.g., Johnson et al., 2018; Leis et al., 2014; McNamara et al., 2019), various confounders are included
in the main analyses. First, mothers reported on their maternal age, level of education, and parity via an online questionnaire around
12 weeks of gestation. Second, obstetric measures (i.e., gestational age at birth and birth weight) were collected via obstetric records
by a research midwife. Third, prenatal distress was assessed using the self-rated 11-item subscale negative affect of the TPDS (Pop
et al., 2011), which demonstrated good validity and reliability in 1739 pregnant women (Boekhorst et al., 2020). Items concern
worries about the pregnancy, upcoming delivery, and postpartum period (e.g., health of the baby, weight gain after pregnancy) and are
rated on a 4-point Likert scale (0 = not at all, 1 = sometimes, 2 = often 3 = very much). Subscale scores range from 0 (no pregnancy

**
Fig. 2. Standardized coefficients of pathways in three theoretical models testing direct and indirect effects. Note. *p < .05; p < .01.

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distress) to 33 (much pregnancy distress). Reliability in the current study was good (α = 0.77). Fourth, depressive symptoms were
assessed during pregnancy (32 weeks of gestation) and 2 years after childbirth with the self-rated 10-item Edinburgh Depression Scales
(EDS-10; Cox et al., 1987). The Dutch version of the EDS was validated among pregnant women (Bergink et al., 2011) and was
demonstrated to be a reliable measurement of depression in the postpartum period (Cox et al., 1987). Items (e.g., “I have been so
unhappy that I have been crying”) are rated on a 4-point scale ranging from 0 to 3. Total scores vary from 0 to 30 with higher scores
reflecting more depressive symptoms. Scores ≥ 10 (prenatal administration) or ≥ 13 (postnatal administration) indicated clinically
significant levels of depressive symptoms (Bergink et al., 2011; Cox et al., 1987). In the current study, reliability was good (α = 0.84
and 0.87 for administration during pregnancy and 2 years after birth, respectively).

1.4. Statistical analyses

All statistical analyses were conducted in Statistical Package for the Social Sciences (IBM SPSS version 28.0). First, independent
samples t-test and Chi Square tests were conducted to identify any differences in demographics and study variables between the
subsample of women in the current study and a sample of women who completed questionnaires on maternal-infant bonding in the
original cohort study, but did not participate in the cohort’s follow up study. Significant differences with small-to-medium effect sizes
of Cohen’s d > 0.30 or Cramer’s V > 0.20 were considered as clinically relevant. Second, missing values in the data were inspected.
Information on gestational age at birth and birth weight was missing for respectively two and three participants (1%). Further data
were complete. Little’s Missing Completely at Random (MCAR) Test was not significant (χ 2(321) = 326.15, p = .41), indicating that
the data were missing completely at random. Power analyses in the software program G*Power identified a minimum sample size of
109 participants for an effect size of f2 = .15, alpha of.05, and power of.80. Based on the random and small proportion of missingness,
resulting in a minimum loss of power and generalizability, cases with missing values were listwise deleted. Third, Pearson’s r cor­
relation coefficients were calculated between pre- and postnatal maternal-infant bonding, pre- and postnatal partner support, child
social-emotional development, and covariates.
For the main analyses, path analysis was conducted by using the IBM SPSS Amos version 28.0 (Arbuckle, 2014). As an extended
version of regression analyses, path analysis allows for testing more complex models that include multiple variables or paths, as well as
comparing different theoretical models (Streiner, 2005). Three models were analyzed to see which model provided the best fit for the
data. All three models included prenatal partner support as an exogenous variable (not influenced by other variables), and postnatal
bonding, postnatal partner support, and child social-emotional development as endogenous variables, whereas for prenatal bonding
this differed for each model. Based on findings in earlier literature, in all three models, direct paths were set up from pre- to postnatal
bonding, pre- to postnatal partner support, and pre- and postnatal bonding to child social-emotional development. Additional paths
varied for each model as earlier research was either absent or ambiguous. In the first model, prenatal bonding was included as an
exogenous variable and additional direct paths were set up from pre- and postnatal partner support to child social-emotional devel­
opment, leading to the following indirect paths: (1) prenatal bonding to child social-emotional development mediated by postnatal
bonding and (2) prenatal partner support to child social-emotional development mediated by postnatal partner support (see Fig. 2. A).

Table 1
Demographics and descriptive statistics of women participating in the current study and the original cohort.
Study sample (n = 227) Original cohort (n = 566)

N (%) M (SD) Min Max N (%) M (SD) t / χ2 d/V

Demographics and covariates

Maternal age 31.07 (3.48) 22 42 30.35 (3.62) 2.54* .20
Maternal educationa 178 (78) 342 (62) 19.21 0.16
Parityb 87 (38) 284 (52) 17.30** .15
Gestational age at start in weeks 32.17 (0.94) 30 41 32.22 (0.81) -0.76 0.06
Gestational age at birth in weeks 39.83 (1.25) 35 42 39.80 (1.36) -1.32 0.02
Birth weight in grams 3604 (519) 1800 5366 3469 (475) 2.05** .27
Child age at follow up in months 24.40 (0.61) 23 26
Child sexc 114 (51) 271 (49) 0.58 0.02
Prenatal distress 6.62 (4.44) 0 20 5.71 (3.88) 2.19* .22
Prenatal depressive symptoms 5.76 (4.53) 0 21 4.47 (3.79) 3.78** .31
Maternal depressive symptoms 5.16 (4.16) 0 21
Study variables
Prenatal maternal-infant bonding 11.24 (2.54) 5 15 12.77 (2.22) -7.96** .64
Postnatal maternal-infant bonding 12.83 (2.04) 6 15 14.03 (1.57) -7.96** .66
Prenatal partner support 9.81 (2.76) 2 15 10.66 (2.81) -3.87** .31
Postnatal partner support 15.50 (3.50) 4 20 16.51 (3.22) -3.88** .30
Social-emotional development 96.94 (10.76) 70 119

Note. The original cohort includes participants who completed questionnaires on maternal-infant bonding but did not participate in the follow up.
a
Reference category is higher vocational education or university degree.
b
Reference category is primiparous.
c
Reference category is boy.
*
p < .05;
**
p < .01.

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To test potential other mediating effects of postnatal bonding, the second model included prenatal bonding as an endogenous variable
and paths were set up from prenatal partner support to prenatal bonding, and from postnatal partner support to postnatal bonding.
This led to two additional indirect paths that were analyzed: (1) prenatal partner support to child social-emotional development
through postnatal partner support and pre- and postnatal bonding, and (2) postnatal partner support to child social-emotional
development through postnatal bonding (see Fig. 2. B). In the third model, direct paths from pre- and postnatal partner support to
child social-emotional development were omitted to test whether the model fit would improve when only indirect paths from partner
support to child social-emotional development were included (see Fig. 2. C).
To assess the overall model fit, the following criteria were used: a nonsignificant chi-square, a Comparative Fit Index (CFI) and
Goodness of Fit Index (GFI) close to 1, and root mean square error of approximation (RMSEA) < 0.05. In order to determine which
model demonstrated the relatively best fit, Chi Square difference tests were performed to compare the “full” model including all
parameters (model 2) with the “smaller” models (model 1 and 3) with fewer parameters and more degrees of freedom. An insignificant
Chi Square value (CMIN) indicated that the smaller model was to prefer over the full model. In addition, the Akaike Information
Criterion (AIC) was assessed. The model with the smallest AIC value was concluded to be the best fit for the data (Kline, 2010).
Additionally, standardized coefficients were assessed for each separate path, as well as direct and indirect effects. To assess significance
of direct and indirect effects, bootstrapping was performed with 5000 samples and 95% confidence intervals (Kline, 2010). Maternal
age, maternal education, parity, gestational age at birth, birth weight, maternal depressive symptoms during pregnancy, and preg­
nancy distress of the mother were included as covariates.

2. Results

2.1. Preliminary analyses

Demographics are presented in Table 1, as are participants’ average scores on depressive symptoms. Of the women who partici­
pated in the follow up study, scores on depressive symptoms were equal to or greater than the clinical cutoff for 41 women (18%;
assessed at 32 weeks of gestation) and 11 women (5%; assessed 2 years after childbirth). Independent samples t-tests and Chi-Square
tests revealed significant differences between the subsample of women as used in the current study (N = 227) and women who
completed maternal-infant bonding questionnaires during pregnancy and postpartum but did not participate in the cohort’s follow up
study (N = 566), see Table 1. Women in the current study were slightly older, more often highly educated, and more often multiparous
than women in the original cohort (however all differences showed small effect sizes). No significant differences were found for
gestational age at the start of participation or child sex. Regarding the study variables, women in the current sample showed signif­
icantly lower levels of maternal-infant bonding and indicated less partner support during pregnancy and postpartum than women in
the original cohort. In addition, depressive symptoms and distress during pregnancy were higher in the current sample, and birth
weight was lower. Differences in pre- and postnatal bonding, pre- and postnatal partner support, and depressive symptoms were
clinically relevant (with Cohen’s d ranging from 0.30− 0.66). Bivariate correlations between maternal-infant bonding, partner support,
child social-emotional development, and covariates are presented in Table 2. Prenatal maternal-infant bonding was positively asso­
ciated to postnatal maternal-infant bonding and prenatal partner support was positively associated to postnatal partner support. In
addition, a positive correlation was found between maternal-infant bonding and partner support, both prenatally and postnatally.
Child social-emotional development was positively associated with pre- and postnatal maternal-infant bonding, as well as with pre­
natal partner support, but not with postnatal partner support.

Table 2
Bivariate correlations.
1 2 3 4 5 6 7 8 9 10 11 12

Study variables
1 Prenatal maternal-infant bonding
2 Postnatal maternal-infant bonding 0.27**
3 Prenatal partner support 0.36** .18**
4 Postnatal partner support 0.19** .24** .48**
5 Social-emotional development 0.16* .19** .15* .12
Covariates
6 Maternal age -0.08 -0.02 -0.14* .04 0.02
7 Maternal education -0.22** -.07 -0.09 0.06 0.10 0.34**
8 Parity 0.00 -0.07 -0.29** -.11 0.09 0.37** .19**
9 Gestational age at birth in weeks -0.08 0.01 -0.03 -0.01 0.07 0.14* .13* .14*
10 Birth weight in grams -0.10 -0.08 -0.08 -0.10 -0.00 0.14* .10 0.34** .52**
11 Prenatal distress -0.08 -0.13* -.21** -.21** -.13 -0.07 -0.22** -.12 -0.09 0.06
12 Prenatal depressive symptoms -0.19** -.13* -.46** -.30** -.12 -0.01 0.02 0.10 -0.03 0.08 0.41**
13 Maternal depressive symptoms -0.04 -0.20** -.19** -.24** -.08 0.03 0.03 0.02 -0.09 0.01 0.44** .45**
**
Note. *p < .05; p < .01. Prenatal determinants were assessed at 32 weeks of gestation; postnatal determinants were assessed 8 months postpartum;
social-emotional development and maternal depressive symptoms were assessed at 2 years of the child’s age.

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2.2. Path analyses

Path analysis demonstrated an overall good fit of the first model that included direct paths from pre- and postnatal bonding and
partner support to child social-emotional development (χ2 (3) = 5.93, p = .115, CFI = 0.99, GFI = 1.00), although RMSEA = 0.066.
The second model, including additional paths from partner support to bonding, showed a good fit as well (χ2 (2) = 0.52, p = .770; CFI
= 1.00; GFI = 1.00; RMSEA = 0.00), as did the third model where direct paths from partner support to child-social emotional
development were omitted and only indirect effects of partner support were tested (χ2 (5) = 2.98, p = .703, CFI = 1.00, GFI = 1.00,
RMSEA = 0.00). Chi Square differences tests comparing the second with the first and third model demonstrated that the smaller first
(CMIN (2) = 3.42, p = .181) and third models (CMIN (2) = 1.55, p = .461) were to prefer over the full second model. The AIC
demonstrated the relatively best fit for the third model (AIC = 174.98), compared to the first and second model (AIC = 181.93 and
178.52, respectively). Standardized coefficients of separate paths in each model are presented in Fig. 2. The statistics in the text are
derived from the third model, as this model demonstrated the best fit. Paths from pre- to postnatal bonding (β = 0.25, SE = 0.07, CI
[0.11–0.38], p = .001) and from pre- to postnatal partner involvement were significant (β = 0.47, SE = 0.06, CI[0.34–0.59] p = .001),
i.e., higher levels of bonding and partner support during pregnancy were associated with higher levels of bonding and partner support
postpartum. In addition, maternal-infant bonding and partner support were positively related, both during pregnancy (β = 0.37, SE =
0.07, CI[0.22–0.50], p < .001) and in the postpartum period (β = 0.16, SE = 0.08, CI[0.00–0.30], p = .048). To statistically compare
the strength of the associations between partner support and bonding in the pre- and postnatal period, we used a z-test in which the
difference in the regression coefficients was divided by the root of the average squared standard errors. Results indicated that the
association was significantly stronger in the prenatal period compared to the association as found in the postnatal period (z = 3.23,
p = .001). Only postnatal bonding was directly associated with child social-emotional development (β = 0.16, SE = 0.07, CI
[0.03–0.29], p = 020). Stronger maternal-infant bonding in the postpartum period, predicted better social-emotional capacities in
early childhood.
Prenatal bonding was not directly related to child social-emotional development, but indirect effects as mediated by postnatal
bonding were significant (β = 0.04, SE = 0.02, CI[0.01–0.09]). Thus, stronger prenatal bonding was associated with better social-
emotional development of children at 2 years of age through stronger postnatal bonding. Prenatal partner support was not directly
related to child social-emotional development, but an indirect effect was found through postnatal partner support and pre- and
postnatal bonding (β = 0.07, SE = 0.03, CI[0.01–0.14]). This indirect effect of prenatal partner support was only significant in the
third model, which included no direct paths from pre- and postnatal partner support to child social-emotional development. Further,
an indirect effect was found of postnatal partner support on child social-emotional development, but only indirect though postnatal
bonding (β = 0.03, SE = 0.02, CI[0.00–0.08]).
Concerning the covariates, maternal education was negatively associated with prenatal bonding (β = − 0.21, p = .001). Parity was
positively associated with prenatal bonding (β = 0.20, p = .011) and prenatal partner support (r = − 0.29, p < .001). In addition,
maternal age was negatively related to prenatal partner support (r = − 0.15, p = .020), as were prenatal distress (r = − 0.21, p = .001),
and depressive symptoms during pregnancy (r = − 0.47, p < .001) and 2 years after childbirth (r = − 0.20, p = .004). Gestational age
at birth and birth weight were unrelated to any of the study variables and none of the covariates was associated with child social-
emotional development. Overall, conducting the analyses without covariates yielded similar results, apart from demonstrating a
poorer fit for the first model with a significant Chi Square (χ2 (3) = 8.46, p = .037).

3. Discussion

The current study examined maternal-infant bonding and partner support during pregnancy and postpartum, and their associations
with early child social-emotional development. Analyses revealed that maternal-infant bonding during pregnancy was positively
related to maternal-infant bonding in the postpartum period, and that both were associated with better social-emotional development
in 2-year-old children. More specifically, stronger prenatal maternal-infant bonding was related to better social-emotional capacities,
but only indirectly as mediated by postnatal maternal-infant bonding. In addition, more partner support during pregnancy was
associated with more partner support postpartum, and both were positively related to pre- and postnatal maternal-infant bonding.
Furthermore, more partner support during pregnancy and postpartum was positively associated to better social-emotional develop­
ment of the child at 2 years of age, although only indirectly through maternal-infant bonding.
As hypothesized, feelings of prenatal maternal-infant bonding were positively associated to maternal-infant bonding in the post­
partum period. This was in line with a systematic review that found the strength of prenatal bonding to be predictive of maternal-infant
bonding in early childhood (Tichelman et al., 2019). Also, the effect sizes found in the present study were similar to other studies that
examined associations between maternal-infant bonding during pregnancy and 6–24 months postpartum (De Cock et al., 2016; De
Cock et al., 2017; Le Bas et al., 2021). Our findings support the notion that an emotional connection from mother to child originates in
pregnancy and that experiencing positive feelings towards the fetus promotes positive maternal-infant bonding after birth.
In addition, we found that maternal-infant bonding was positively associated with child social-emotional development. For pre­
natal bonding, only an indirect effect was found through postnatal bonding quality. Thus, stronger maternal-infant bonding during
pregnancy was related to stronger bonding in the postpartum period and subsequently to better social-emotional capacities of children
at 2 years of age. Furthermore, we found a direct association between postnatal mother-infant bonding and better social emotional
development. These findings were in line with our hypotheses, as well as with previous studies that associated prenatal maternal-infant
bonding with positive social-emotional outcomes (Branjerdporn et al., 2017; Le Bas et al., 2021; Le Bas et al., 2020) and demonstrated
stronger feelings of bonding 2–8 months postpartum to predict more social-emotional competencies 6–12 months after birth (Behrendt

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N. de Waal et al. Infant Behavior and Development 72 (2023) 101871

et al., 2019; Mason et al., 2011). Presumably, mothers who feel emotionally connected to their child are more motivated to provide
adequate caregiving and engage in interaction, which would promote parental sensitivity and subsequently social-emotional capacities
of the child (Behrendt et al., 2019; Medina et al., 2021). Poor bonding on the other hand, has been associated with maternal depression,
both in earlier research (Faisal-Cury et al., 2020; Rolle et al., 2020) as bivariate in the current study. In turn, depression is a known risk
factor for insensitive parenting behavior (Bernard et al., 2018; Coyne et al., 2007) and social-emotional difficulties in early childhood
(Junge et al., 2017; Mason et al., 2011). Although the current study assessed postnatal bonding in terms of maternal feelings towards
the child and not bonding-related parenting behavior, the fact that only indirect effects of prenatal bonding on child social-emotional
development were found, may further suggest that parental behavior in the postpartum period can be an important mechanism in
explaining the relation between maternal-infant bonding and child development, at least in the current sample. Alternatively, mothers
with higher levels of bonding might also have more positive relationships with other individuals, which may be indicative for having
adequate communication skills in social interactions, as well as emotion regulation capacities (Behrendt et al., 2019; Lopes et al.,
2011). As such, these mothers may provide a better role model for their children (Morris et al., 2007).
Similar to maternal-infant bonding, the level of prenatal partner support was positively related to the level of partner support in the
postpartum period. Thus, a partner who was perceived as more supportive during pregnancy, was also perceived as more supportive
after birth. These results were consistent with our hypothesis, as well as with earlier work that found paternal involvement during
pregnancy to be related to fathers’ engagement in postnatal caregiving (Zvara et al., 2013). Given the positive child outcomes that are
related to father involvement in early childhood (Wilson & Prior, 2011), our findings emphasize the importance of encouraging fathers
to actively participate in their partners’ pregnancies and to include them in prenatal health care.
In accordance with our hypothesis and previous work (Cuijlits et al., 2019; da Rosa et al., 2021; De Cock et al., 2016), partner
support was positively associated with maternal-infant bonding, both during pregnancy and in the postpartum period. In the transition
to parenthood, women are particularly vulnerable to develop mental health problems such as depression and anxiety (Parfitt & Ayers,
2014), which may reflect negatively on their perceptions of the fetus or child (Cornish et al., 2006). Having a partner who provides
emotional support and who is understanding, might protect against developing such mental health problems (Pilkington et al., 2016;
Stapleton et al., 2012) and subsequently promote positive feelings towards the child, perhaps even more so in a sample of women with
heightened levels of depression. Our results demonstrated that the association between partner support and maternal-infant bonding in
pregnancy was stronger compared to this relation in the postpartum period. Possibly, this can be explained by the fact that the current
study assessed partner support as perceived by mother, rather than actual involvement in terms of engagement in pregnancy activities
or hours spent on childcare tasks. Pregnancy can be a stressful period and being able to share any uncertainties or concerns, for
example regarding fetal growth, the upcoming delivery, or future parenting qualities, might be crucial (Darvill et al., 2010), whereas in
early parenthood, mothers might benefit more from practical support (i.e., involvement in terms of actual hours spent with the child)
to unburden them from childcare tasks (Kirova & Snell, 2019).
Our assessment of mothers’ perception of partner support (i.e., whether mothers felt supported by their partner) rather than actual
involvement, might also explain why this was only indirectly related to social-emotional development of the child through maternal-
infant bonding, while no direct association was found. Earlier studies that found an association between paternal involvement and
children’s social-emotional capacities, included the amount of hours that fathers reported they spent with their child or on childcare
tasks (Dubeau et al., 2012; Flouri et al., 2016), fathers’ perception of parental roles (e.g., how much importance they attribute to
play-interactions with the child; Dubeau et al., 2012), or paternal support as rated by the child itself (Dubowitz et al., 2001). The
various measures of father involvement were also found to be differently related to child outcomes. For example, fathers’ time spent on
household and childcare tasks was related to prosocial behavior of the child, whereas paternal availability and presence in the home
was not (Dubeau et al., 2012), further suggesting that the type of involvement measure plays a role. Furthermore, there seems to be a
discrepancy in maternal and paternal ratings of father’s involvement in childcare. For example, fathers have been found to report a
greater frequency of involvement compared to mothers’ rating of their partners’ engagement (Mikelson, 2008), potentially explaining
the inconsistent findings. Moreover, mothers’ emotional perception of the support provided by her partner might affect maternal
mental health and behavior specifically, whilst partner involvement as measured in the previous studies can potentially have a more
direct effect on child development. It should be noted that the selection of the current sample may also play a role, as this was, in part,
based on elevated levels of depression which are known to influence how interactions with others are perceived and interpreted
(Kupferberg et al., 2016). Nevertheless, we demonstrated that partner support was indirectly associated with social-emotional
development of the child through maternal-infant bonding, emphasizing the importance of having a supportive partner throughout
pregnancy and after birth.
Strengths of the present study are the longitudinal design with assessments during pregnancy and the postpartum period, as well as
a follow up at 2 years after childbirth. In contrast to earlier studies, maternal-infant bonding and partner support were assessed both
pre- and postnatally, which enabled analyses of different pathways and direct and indirect effects on social-emotional development in
early life. In addition, maternal-infant bonding during pregnancy and the postpartum period were assessed using the same ques­
tionnaire, allowing for a reliable assessment of bonding throughout the transition into parenthood. Furthermore, we controlled for
various potential confounders in the analyses, enabling us to examine the independent contribution of maternal-infant bonding and
partner support on child development. However, this study also has limitations. First, women participating in the current study were
overall highly educated and few had an ethnic minority background, which may limit generalizability to the general population.
Second, clinically relevant differences were found between the current sample and women participating in the original cohort (e.g.,
lower levels of maternal-infant bonding). This was not unexpected since one of the selection criteria for the follow up study was
elevated levels of depression during pregnancy and/or postpartum, which have been associated with, among others, impaired
maternal-infant bonding. These selection criteria may have had an impact on our results in an unknown way and further limit

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N. de Waal et al. Infant Behavior and Development 72 (2023) 101871

generalizability of the current findings, since we included a relatively high-risk sample that was potentially characterized by lower
levels of bonding. This may be particularly relevant for prenatal bonding since this represent thoughts and fantasies on the child, which
may be more strongly affected by feelings of depression. Third, mothers self-reported on their feelings towards their child and
perceived partner support, as well as on their children’s social-emotional capacities, which might potentially bias the results. However,
we controlled for maternal depressive symptoms during pregnancy and at times of completing the questionnaire on child social-
emotional development, taking potential bias due to depression into account.
Future research might consider examining the role of parenting behavior (e.g., parental sensitivity) and maternal social compe­
tencies in relation to maternal-infant bonding and child development. Partner involvement could be assessed in terms of hours spent on
childcare tasks, specifically using diary studies or experience sampling methods, for example. In addition, it would be interesting to
include partner involvement alongside perceived partner support to examine associations with maternal-infant bonding, as well as
potentially more direct effects on child development. Finally, facets of social-emotional development could be separated and examined
individually, as different patterns of relations with bonding and partner support could emerge. The present study contributed to the
literature by examining different pathways from maternal-infant bonding and partner support to social-emotional development of the
child. Complementary to earlier work, pre- and postnatal measures were included, and direct and indirect effects were tested. Our
results confirm earlier findings that an emotional bond from mother to child develops during pregnancy and that this lays a foundation
for positive maternal-infant bonding after birth and social-emotional capacities in early childhood. Additionally, having a supportive
partner during pregnancy and postpartum, might be essential for the development of optimal maternal-infant bonding. Our results
emphasize the importance of monitoring maternal-infant bonding quality during pregnancy and postpartum, and actively involving
partners in pregnancy and prenatal health care.

Ethical approval

The HAPPY study was approved by the Ethical Board of Tilburg University and has been evaluated by the Medical Ethical Com­
mittee of the Máxima Medical Centre Veldhoven. The follow up study was approved by the Medical Ethics Committee of the Máxima
Medical Centre (protocol number NL54558.015.15). The study has been carried out in accordance with the Code of Ethics of the World
Medical Association (Declaration of Helsinki).

Funding

This work was supported by Stichting de Weijerhorst.

CRediT authorship contribution statement

Noor de Waal: Conceptualization, Methodology, Formal analysis, Writing – original draft. Myrthe G.B.M. Boekhorst: Concep­
tualization, Methodology, Supervision, Writing - review & editing. Ivan Nyklíček: Conceptualization, Methodology, Writing – review
& editing, Supervision. Victor J.M. Pop: Conceptualization, Methodology, Writing – review & editing, Supervision.

Declarations of interest

None.

Data Availability

Data will be made available on request.

Acknowledgements

The authors thank all midwife practices for their support in recruitment and all women for their participation in the study. In
addition, the authors thank all the researchers for their contribution to the data collection.

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