Maternal–fetal attachment protects against postpartum anxiety: the mediating role of postpartum bonding and partnership satisfaction



Maternal mental disorders develop frequently during the perinatal period, and can have detrimental effects on the developing bond between a mother and her child. While depression has already been widely associated with bonding disorders, the link between anxiety disorders and maternal–fetal attachment has received only limited attention. This study aimed to explore the link between maternal–fetal attachment in the third trimester and postpartum anxiety, as previous research has suggested a potentially protective association. Additionally, we hypothesized a mediating influence of postpartum bonding and partnership satisfaction as additional measurements of attachment capacity.


Self-report questionnaires assessing maternal–fetal attachment, postpartum bonding, anxiety, depression, and partnership quality were completed at three time points: third trimester (T1, N = 324), first week postpartum (T2, N = 249), and 4 months postpartum (T3, N = 166). Conditional process analyses were used to test for mediation.


A statistically significant negative correlation of maternal–fetal attachment was found with maternal anxiety postpartum. Overall, the analyses supported the mediation hypothesis. There was a significant, indirect effect of maternal–fetal attachment during pregnancy on state anxiety in the first week postpartum, mediated through postpartum bonding quality and partnership satisfaction. All three variables together accounted for 18.25% (state anxiety) or 30.35% (trait anxiety) of the variance in postpartum anxiety.


Our results showed that a close maternal–fetal attachment buffers postpartum symptoms of anxiety, partially mediated through postpartum bonding and partnership satisfaction. Therefore, strengthening the maternal–fetal attachment and the partnership during pregnancy has the potential to reduce maternal postpartum symptoms of anxiety.

This is a preview of subscription content, access via your institution.

Fig. 1


  1. 1.

    Achtergarde S, Muller JM, Postert C, Wessing I, Mayer A, Romer G (2015) Attachment patterns and their relation to the development of anxiety symptoms in childhood and adolescence. Prax Kinderpsychol Kinderpsychiatr 64(7):496–526.

    Article  PubMed  Google Scholar 

  2. 2.

    Andrews G, Sanderson K, Slade T, Issakidis C (2000) Why does the burden of disease persist? Relating the burden of anxiety and depression to effectiveness of treatment. Bull World Health Organ 78(4):446–454

    CAS  PubMed  PubMed Central  Google Scholar 

  3. 3.

    Apter G, Bobin A, Genet MC, Gratier M, Devouche E (2017) Update on mental health of infants and children of parents affected with mental health issues. Curr Psychiatry Rep 19(10):72.

    Article  PubMed  Google Scholar 

  4. 4.

    Apter G, Devouche E, Gratier M (2011) Perinatal mental health. J Nerv Ment Dis 199(8):575–577.

    Article  PubMed  Google Scholar 

  5. 5.

    Arteche A, Joormann J, Harvey A, Craske M, Gotlib IH, Lehtonen A, Counsell N, Stein A (2011) The effects of postnatal maternal depression and anxiety on the processing of infant faces. J Affect Disord 133(1–2):197–203.

    Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Asselmann E, Wittchen HU, Petzoldt J, Martini J (2016) Peripartum changes in partnership quality among women with and without anxiety and depressive disorders prior to pregnancy: a prospective-longitudinal study. Arch Womens Ment Health 19(2):281–290.

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Babb JA, Deligiannidis KM, Murgatroyd CA, Nephew BC (2015) Peripartum depression and anxiety as an integrative cross domain target for psychiatric preventative measures. Behav Brain Res 276:32–44.

    Article  PubMed  Google Scholar 

  8. 8.

    Bacciagaluppi M (2015) Arieti and Bowlby: convergence and direct influence. Am J Psychoanal 75(3):320–332.

    Article  PubMed  Google Scholar 

  9. 9.

    Bergant AM, Nguyen T, Heim K, Ulmer H, Dapunt O (1998) German language version and validation of the Edinburgh postnatal depression scale. Dtsch Med Wochenschr 123(3):35–40.

    CAS  Article  PubMed  Google Scholar 

  10. 10.

    Borri C, Mauri M, Oppo A, Banti S, Rambelli C, Ramacciotti D, Montagnani MS, Camilleri V, Cortopassi S, Bettini A, Ricciardulli S, Rucci P, Montaresi S, Cassano GB (2008) Axis I psychopathology and functional impairment at the third month of pregnancy: results from the perinatal depression-research and screening unit (PND-ReScU) study. J Clin Psychiatry 69(10):1617–1624

    Article  Google Scholar 

  11. 11.

    Bowlby J (1977) The making and breaking of affectional bonds: i. Aetiology and psychopathology in the light of attachment theory. Br J Psychiatry 130:201–2010

    CAS  Article  Google Scholar 

  12. 12.

    Bowlby J (1982) Attachment. Basic Books, New York

    Google Scholar 

  13. 13.

    Bowlby J (1988) Developmental psychiatry comes of age. Am J Psychiatry 145(1):1–10.

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Brennan KA, Clark CL, Shaver PR (1998) Self-report measures of adult attachment: an integrative overview. Guilford Press, New York

    Google Scholar 

  15. 15.

    Busonera A, Cataudella S, Lampis J, Tommasi M, Zavattini GC (2017) Psychometric properties of the postpartum bonding questionnaire and correlates of mother-infant bonding impairment in Italian new mothers. Midwifery 55:15–22.

    Article  PubMed  Google Scholar 

  16. 16.

    Cattell RB (1966) Handbook of multivariate experimental psychology. Rand McNally, Chicago

    Google Scholar 

  17. 17.

    Chambless DL, Fauerbach JA, Floyd FJ, Wilson KA, Remen AL, Renneberg B (2002) Marital interaction of agoraphobic women: a controlled, behavioral observation study. J Abnorm Psychol 111(3):502–512

    Article  Google Scholar 

  18. 18.

    Cox JL, Holden JM, Sagovsky R (1987) Detection of postnatal depression. Development of the 10-item Edinburgh postnatal depression scale. Br J Psychiatry 150:782–786

    CAS  Article  Google Scholar 

  19. 19.

    Cranley MS (1981) Development of a tool for the measurement of maternal attachment during pregnancy. Nurs Res 30(5):281–284

    CAS  Article  Google Scholar 

  20. 20.

    Cuming S, Rapee RM (2010) Social anxiety and self-protective communication style in close relationships. Behav Res Ther 48(2):87–96.

    Article  PubMed  Google Scholar 

  21. 21.

    Ding XX, Wu YL, Xu SJ, Zhu RP, Jia XM, Zhang SF, Huang K, Zhu P, Hao JH, Tao FB (2014) Maternal anxiety during pregnancy and adverse birth outcomes: a systematic review and meta-analysis of prospective cohort studies. J Affect Disord 159:103–110.

    Article  PubMed  Google Scholar 

  22. 22.

    Doss BD, Rhoades GK, Stanley SM, Markman HJ (2009) The effect of the transition to parenthood on relationship quality: an 8-year prospective study. J Pers Soc Psychol 96(3):601–619.

    Article  PubMed  PubMed Central  Google Scholar 

  23. 23.

    Doster A, Wallwiener S, Muller M, Matthies LM, Plewniok K, Feller S, Kuon RJ, Sohn C, Rom J, Wallwiener M, Reck C (2018) Reliability and validity of the German version of the Maternal–Fetal attachment scale. Arch Gynecol Obstet 297(5):1157–1167.

    Article  PubMed  Google Scholar 

  24. 24.

    Dubber S, Reck C, Muller M, Gawlik S (2015) Postpartum bonding: the role of perinatal depression, anxiety and maternal-fetal bonding during pregnancy. Arch Womens Ment Health 18(2):187–195.

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    Edhborg M, Nasreen HE, Kabir ZN (2011) Impact of postpartum depressive and anxiety symptoms on mothers’ emotional tie to their infants 2-3 months postpartum: a population-based study from rural Bangladesh. Arch Womens Ment Health 14(4):307–316.

    Article  PubMed  Google Scholar 

  26. 26.

    Field T (2018) Postnatal anxiety prevalence, predictors and effects on development: a narrative review. Infant Behav Dev 51:24–32.

    Article  PubMed  Google Scholar 

  27. 27.

    Fraley RC, Waller NG, Brennan KA (2000) An item response theory analysis of self-report measures of adult attachment. J Pers Soc Psychol 78(2):350–365

    CAS  Article  Google Scholar 

  28. 28.

    Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T (2005) Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol 106(5 Pt 1):1071–1083.

    Article  PubMed  Google Scholar 

  29. 29.

    Gillath O, Bunge SA, Shaver PR, Wendelken C, Mikulincer M (2005) Attachment-style differences in the ability to suppress negative thoughts: exploring the neural correlates. Neuroimage 28(4):835–847.

    Article  PubMed  Google Scholar 

  30. 30.

    Gobel A, Stuhrmann LY, Harder S, Schulte-Markwort M, Mudra S (2018) The association between maternal-fetal bonding and prenatal anxiety: an explanatory analysis and systematic review. J Affect Disord 239:313–327.

    Article  PubMed  Google Scholar 

  31. 31.

    Goodman JH, Guarino A, Chenausky K, Klein L, Prager J, Petersen R, Forget A, Freeman M (2014) CALM Pregnancy: results of a pilot study of mindfulness-based cognitive therapy for perinatal anxiety. Arch Womens Ment Health 17(5):373–387.

    Article  PubMed  PubMed Central  Google Scholar 

  32. 32.

    Gottman JMKL (1989) Effects of marital discord on young children’s peer interaction and health. Dev Psychol 25:373–381.

    Article  Google Scholar 

  33. 33.

    Grant KA, McMahon C, Austin MP (2008) Maternal anxiety during the transition to parenthood: a prospective study. J Affect Disord 108(1–2):101–111.

    Article  PubMed  Google Scholar 

  34. 34.

    Grossmann K (2004) GK. Bindungen—das gefüge psychischer sicherheit stuttgart, Klett-Cotta

    Google Scholar 

  35. 35.

    Hahlweg (1996) Fragebogen zur partnerschaftsdiagnostik. Hogrefe, Goettingen

    Google Scholar 

  36. 36.

    Hahlweg K (1986) Partnerschaftliche Interaktion. Röttger, Dyadic interaction München

    Google Scholar 

  37. 37.

    Hart R, McMahon CA (2006) Mood state and psychological adjustment to pregnancy. Arch Womens Ment Health 9(6):329–337.

    CAS  Article  PubMed  Google Scholar 

  38. 38.

    Hendrick V, Altshuler L, Strouse T, Grosser S (2000) Postpartum and nonpostpartum depression: differences in presentation and response to pharmacologic treatment. Depress Anxiety 11(2):66–72

    CAS  Article  Google Scholar 

  39. 39.

    Hinz A, Stöbel-Richter Y, Brähler E (2001) Der partnerschaftsfragebogen (PFB). Diagnostica Zeitschrift für Psychologische Diagnostik und Differentielle Psychologie 47:132–141

    Google Scholar 

  40. 40.

    Kaitz M, Maytal HR, Devor N, Bergman L, Mankuta D (2010) Maternal anxiety, mother-infant interactions, and infants’ response to challenge. Infant Behav Dev 33(2):136–148.

    Article  PubMed  Google Scholar 

  41. 41.

    Kroll-Desrosiers AR, Nephew BC, Babb JA, Guilarte-Walker Y, Moore Simas TA, Deligiannidis KM (2017) Association of peripartum synthetic oxytocin administration and depressive and anxiety disorders within the first postpartum year. Depress Anxiety 34(2):137–146.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  42. 42.

    Kumar RC (1997) “Anybody’s child”: severe disorders of mother-to-infant bonding. Br J Psychiatry 171:175–181

    CAS  Article  Google Scholar 

  43. 43.

    Little RJA (1988) A test of missing completely at random for multivariate data with missing values. J Am Stat Assoc 83:1198–1202

    Article  Google Scholar 

  44. 44.

    Masi G, Millepiedi S, Mucci M, Poli P, Bertini N, Milantoni L (2004) Generalized anxiety disorder in referred children and adolescents. J Am Acad Child Adolesc Psychiatry 43(6):752–760.

    Article  PubMed  Google Scholar 

  45. 45.

    Matthies LM, Wallwiener S, Muller M, Doster A, Plewniok K, Feller S, Sohn C, Wallwiener M, Reck C (2017) Maternal self-confidence during the first 4 months postpartum and its association with anxiety and early infant regulatory problems. Infant Behav Dev 49:228–237.

    Article  PubMed  Google Scholar 

  46. 46.

    Moehler E, Brunner R, Wiebel A, Reck C, Resch F (2006) Maternal depressive symptoms in the postnatal period are associated with long-term impairment of mother-child bonding. Arch Womens Ment Health 9(5):273–278.

    CAS  Article  PubMed  Google Scholar 

  47. 47.

    Muller ME (1996) Prenatal and postnatal attachment: a modest correlation. J Obstet Gynecol Neonatal Nurs 25(2):161–166

    CAS  Article  Google Scholar 

  48. 48.

    Nonnenmacher N, Noe D, Ehrenthal JC, Reck C (2016) Postpartum bonding: the impact of maternal depression and adult attachment style. Arch Womens Ment Health 19(5):927–935.

    CAS  Article  PubMed  Google Scholar 

  49. 49.

    Reck C, Klier CM, Pabst K, Stehle E, Steffenelli U, Struben K, Backenstrass M (2006) The German version of the postpartum bonding instrument: psychometric properties and association with postpartum depression. Arch Womens Ment Health 9(5):265–271.

    CAS  Article  PubMed  Google Scholar 

  50. 50.

    Reck C, Noe D, Gerstenlauer J, Stehle E (2012) Effects of postpartum anxiety disorders and depression on maternal self-confidence. Infant Behav Dev 35(2):264–272.

    Article  PubMed  Google Scholar 

  51. 51.

    Reck C, Zietlow AL, Muller M, Dubber S (2016) Perceived parenting stress in the course of postpartum depression: the buffering effect of maternal bonding. Arch Womens Ment Health 19(3):473–482.

    CAS  Article  PubMed  Google Scholar 

  52. 52.

    Reck C, Zimmer K, Dubber S, Zipser B, Schlehe B, Gawlik S (2013) The influence of general anxiety and childbirth-specific anxiety on birth outcome. Arch Womens Ment Health 16(5):363–369.

    CAS  Article  PubMed  Google Scholar 

  53. 53.

    Rossen L, Hutchinson D, Wilson J, Burns L, Olsson CA, Allsop S, Elliott EJ, Jacobs S, Macdonald JA, Mattick RP (2016) Predictors of postnatal mother-infant bonding: the role of antenatal bonding, maternal substance use and mental health. Arch Womens Ment Health.

    Article  PubMed  Google Scholar 

  54. 54.

    Saunders H, Kraus A, Barone L, Biringen Z (2015) Emotional availability: theory, research, and intervention. Front Psychol 6:1069.

    Article  PubMed  PubMed Central  Google Scholar 

  55. 55.

    Shapiro AF, Gottman JM, Carrere S (2000) The baby and the marriage: identifying factors that buffer against decline in marital satisfaction after the first baby arrives. J Fam Psychol 14(1):59–70

    CAS  Article  Google Scholar 

  56. 56.

    Shaver P, Mikulincer M (2007) Adult attachment strategies and the regulation of emotion. In: Handbook of emotion regulation. Guilford Press, pp 446–465

  57. 57.

    Spielberger CD, Gorsuch RE, Lushene R (1970) State-trait anxiety inventory palo alto. Consulting Psychologists Press, California

    Google Scholar 

  58. 58.

    Szpunar MJ, Parry BL (2017) A systematic review of cortisol, thyroid-stimulating hormone, and prolactin in peripartum women with major depression. Arch Womens Ment Health.

    Article  PubMed  PubMed Central  Google Scholar 

  59. 59.

    Tietz A, Zietlow AL, Reck C (2014) Maternal bonding in mothers with postpartum anxiety disorder: the crucial role of subclinical depressive symptoms and maternal avoidance behaviour. Arch Womens Ment Health 17(5):433–442.

    CAS  Article  PubMed  Google Scholar 

  60. 60.

    Wallwiener S, Muller M, Doster A, Kuon RJ, Plewniok K, Feller S, Wallwiener M, Reck C, Matthies LM, Wallwiener C (2017) Sexual activity and sexual dysfunction of women in the perinatal period: a longitudinal study. Arch Gynecol Obstet 295(4):873–883.

    Article  PubMed  Google Scholar 

  61. 61.

    Wallwiener S, Muller M, Doster A, Plewniok K, Wallwiener CW, Fluhr H, Feller S, Brucker SY, Wallwiener M, Reck C (2015) Predictors of impaired breastfeeding initiation and maintenance in a diverse sample: what is important? Arch Gynecol Obstet.

    Article  PubMed  PubMed Central  Google Scholar 

  62. 62.

    White MA, Wilson ME, Elander G, Persson B (1999) The Swedish family: transition to parenthood. Scand J Caring Sci 13(3):171–176

    CAS  Article  Google Scholar 

  63. 63.

    Wilson N, Wynter K, Anderson C, Rajaratnam SMW, Fisher J, Bei B (2019) More than depression: a multi-dimensional assessment of postpartum distress symptoms before and after a residential early parenting program. BMC Psychiatry 19(1):48.

    Article  PubMed  PubMed Central  Google Scholar 

  64. 64.

    Zietlow AL, Schluter MK, Nonnenmacher N, Muller M, Reck C (2014) Maternal self-confidence postpartum and at pre-school age: the role of depression, anxiety disorders, maternal attachment insecurity. Matern Child Health J 18(8):1873–1880.

    Article  PubMed  Google Scholar 

Download references


This study was funded by the German Society of Psychosomatic Gynaecology and Obstetrics.

Author information




LMM: data collection and manuscript writing. MM: data collection and management, data analysis, and manuscript writing. AD: data collection and manuscript editing. MW: protocol development. CR: protocol development, data management, and manuscript editing. CS: protocol development and manuscript editing. SW: protocol development, data collection and management, data analysis, and manuscript writing.

Corresponding author

Correspondence to Lina Maria Matthies.

Ethics declarations

Conflict of interest

All authors declare that there is no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Matthies, L.M., Müller, M., Doster, A. et al. Maternal–fetal attachment protects against postpartum anxiety: the mediating role of postpartum bonding and partnership satisfaction. Arch Gynecol Obstet 301, 107–117 (2020).

Download citation


  • Anxiety
  • Depression
  • Perinatal period
  • Bonding
  • Attachment