Neuropsychiatric Disease and Treatment

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ORIGINAL RESEARCHOpen Access Full Text Article

Depression, Anxiety and Primiparity are Negatively
Associated with Mother–Infant Bonding in Japanese
Mothers
This article was published in the following Dove Press journal:
Neuropsychiatric Disease and Treatment

Takaharu Motegi 1
Yuichiro Watanabe 1
Naoki Fukui 1
Maki Ogawa 1
Koyo Hashijiri 1
Ryusuke Tsuboya1
Takuro Sugai 1
Jun Egawa 1
Rie Araki 2
Kazufumi Haino 3
Masayuki Yamaguchi 3
Koji Nishijima 4
Takayuki Enomoto 3
Toshiyuki Someya 1
1

Department of Psychiatry, Niigata
University Graduate School of Medical
and Dental Sciences, Niigata, Japan;
2
Nursing, Niigata University Medical and
Dental Hospital, Niigata, Japan;
3
Department of Obstetrics andGynecology, Niigata University Graduate
School of Medical and Dental Sciences,
Niigata, Japan; 4General Center for
Perinatal, Maternal and Neonatal
Medicine, Niigata University Medical and
Dental Hospital, Niigata, Japan

Correspondence: Yuichiro Watanabe
Department of Psychiatry, Niigata
University Graduate School of Medical
and Dental Sciences, 757 AsahimachidoriIchibancho, Chuo-Ku, Niigata 951-8510,
Japan
Tel +81-25-227-2213
Fax +81-25-227-0777
Email yuichiro@med.niigata-u.ac.jp

Purpose: Postpartum depression is a well-known risk factor, and postpartum anxiety andparity are potential risk factors, for mother–infant bonding disorder. However, few studies
have focused on the relationships among these factors and mother–infant bonding. Thiscross-sectional study explored the associations between depression, anxiety and parity, andmother–infant bonding.
Materials and Methods: Japanese mothers, both primiparas and multiparas, completed theMother-to-Infant Bonding Scale (MIBS) and the Hospital Anxiety and Depression Scale(HADS) one month after childbirth. We performed a stepwise multiple regression analysis
with the forward selection method to assess the effects of HADS anxiety and depression scoresand parity as independent variables on mother–infant bonding as the dependent variable.
Results: A total of 2379 Japanese mothers (1116 primiparas and 1263 multiparas) took partin the study. MIBS score (2.89 ± 2.68 vs 1.60 ± 2.11; p < 0.0001) was significantly higher inprimiparas than in multiparas. HADS anxiety (6.55 ± 4.06 vs 4.63 ± 3.41; p < 0.0001) anddepression (6.56 ± 3.43 vs 5.98 ± 3.20; p < 0.0001) scores were also significantly higher inprimiparas than in multiparas. A stepwise multiple regression analysis with the forward
selection method revealed that HADS depression and anxiety scores and parity weresignificantly associated with MIBS score (p = 0.003, 0.015 and 0.023).
Conclusion: Depression, anxiety and primiparity were negatively associated with mother–
infant bonding one month after childbirth.
Keywords: HADS, Japanese, MIBS, parity, postpartum

Introduction
Bonding disorder is a psychological state that leads to lack of affection andemotional bond with children. Parents with bonding disorder may have feelingsof rejection or even hatred towards their children.1 Early detection and preventionof signs of bonding failure are very important in preventing child abuse, improving
relationships with children, and supporting childcare.2
Systematic reviews have demonstrated that peripartum depression is negatively
associated with mother–infant bonding3,4 and that peripartum anxiety may also
have negative effects on mother–infant bonding.3 These findings remain
controversial,4,5 but identifying and intervening in both depression and anxiety
during the peripartum period are considered critical to prevent bonding disorder.
However, few studies have investigated the effects of peripartum anxiety anddepression simultaneously on mother–infant bonding with small sample sizes.6–11
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http://doi.org/10.2147/NDT.S287036

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Motegi et al

One study found that 5.0% of 280 Japanese primiparas
who were interviewed by trained midwives had experienced a major depressive episode within 3 months ofchildbirth.12 A meta-analysis of self-report questionnaire
surveys found that the prevalence of depression at one
month after childbirth was 14.3% in 108,431 Japanesemothers.13 By contrast, the prevalence of postpartum anxiety has been poorly studied. A self-report questionnaire
survey reported that 26.2% of 1348 Japanese mothers had
experienced anxiety at 3–4 months after childbirth.14 In
Japan, many studies have shown that postpartum depression is negatively associated with mother–infantbonding,6–8,15–19 but few studies have evaluated the effects
of postpartum anxiety on mother–infant bonding.7,8Recent large-scale Japanese studies have provided evidence for associations of primiparity with poor mother–
infant bonding18 and postpartum depression.13,18 However,there is little research, with inconsistent findings, on theinfluence of parity in postpartum anxiety in either Japan8
or elsewhere.4,9,10,20 It is still unclear how depression,anxiety, parity and mother–infant bonding are related inJapanese mothers.
This study aimed to assess whether primiparas showed
poorer mother–infant bonding and worse symptoms ofanxiety and depression than multiparas, and whether
depression, anxiety and primiparity were negatively associated with mother–infant bonding.

Materials and Methods
Ethics Statement
This study followed the principles of the Declaration of
Helsinki and was approved by the Ethics Committee of
Niigata University and the ethics committees of the participating obstetric institutions. Written informed consent
was obtained from all participants.
All relevant data are within the paper. We are not able
to make the underlying data available to readers, because
we do not have the permission of the committees to do so.

ParticipantsThis study is part of the Perinatal Mental Health Research
Project, which has been in progress since March 2017.21
We recruited participants from 34 obstetric institutions in
Niigata Prefecture, Japan, and included pregnant Japanesewomen aged 18 years or older. We excluded pregnant
women with serious physical complications, serious

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pregnancy complications, or severe psychiatric disorders(eg, severe schizophrenia or severe depression).

Measurements
The instruments were administered consecutively and selfcompleted at three time points: early pregnancy (approximately 12–15 weeks), late pregnancy (approximately
30–34 weeks) and postpartum (4 weeks after childbirth).
This study is a sub-analysis of postpartum data up to
December 2019.
The Mother-to-Infant Bonding Scale (MIBS) is a selfreport questionnaire that evaluates the feelings of mothers
towards their babies.22 This scale was originally developed
as an eight-item questionnaire22 and was later modified to
add two additional items.15 The MIBS contains 10 items
that assess mother–infant bonding.15 Each item is gradedon a four-point Likert-type scale (0–3). Higher MIBS
scores indicate worse mother–infant bonding. The
Japanese version of MIBS has been previously
validated15 and is commonly used to assess mother–infantbonding in Japan.7,8,15,16,18,21
The Edinburgh Postnatal Depression Scale (EPDS) is
the most widely used self-report questionnaire for screening for peripartum depression.6,9–11,13,15–19,23–25 However,this scale is not suitable for detecting peripartum anxiety.23
We therefore used the Hospital Anxiety and Depression
Scale (HADS), which is a self-report questionnaire
designed to identify anxiety and depression in nonpsychiatric hospital outpatients.26 It has also been used in
pregnant women.6–8,14,27–37 The HADS includes 14 questions, of which seven assess anxiety (items 1, 3, 5, 7, 9, 11,
and 13) and seven depression (items 2, 4, 6, 8, 10, 12, and
14).26 Each item is graded on a four-point Likert-type
scale (0–3). Higher HADS scores indicate more severe
symptoms of anxiety and depression. The Japanese version
of HADS38 has been validated in a previous study.39

Statistical Analysis
We compared the mean age, MIBS score, and HADS
anxiety and depression scores for primiparas and multiparas using a t-test. To identify potential predictors ofmother–infant bonding, we used simple regression analyses with HADS anxiety and depression scores, parity
and age as independent variables and MIBS score as thedependent variable. We regarded variables with p values
less than 0.1 as potential predictors. We then performeda stepwise multiple regression analysis with the forward
selection method to assess the effects of potential

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predictors on mother–infant bonding. We used theStatistical Package for the Social Sciences (SPSS) version
25 (IBM Japan, Tokyo, Japan) for the statistical analyses.

Independent Variables

MIBS

SRC

p

Adjusted R2

Results
The study participants were 2379 mothers (1116 primiparasand 1263 multiparas). These individuals included 1755
mothers (853 primiparas and 902 multiparas) froma previous study reporting the factor structure of MIBS.21
The age of participants ranged from 18−50 years. Primiparas
were significantly younger than multiparas (mean age ± SD:
31.0 ± 4.96 vs 33.0 ± 4.34 years; Table 1).
We assessed mother–infant bonding and symptoms ofanxiety and depression using MIBS and HADS in 1116
primiparas and 1263 multiparas (Table 1). MIBS score(2.89 ± 2.68 vs 1.60 ± 2.11) was significantly higher inprimiparas than in multiparas. HADS anxiety (6.55 ± 4.06
vs 4.63 ± 3.41) and depression (6.56 ± 3.43 vs 5.98 ± 3.20)scores were also significantly higher in primiparas than in
multiparas. Cronbach’s α values for overall MIBS andHADS, anxiety and depression were 0.885, 0.751, 0.778
and 0.806, respectively.
Using simple regression analysis, we identified HADS
anxiety score (r = 0.500 and p < 0.001), HADS depression
score (r = 0.476 and p < 0.001) and parity (r = −0.264 andp < 0.001), but not age (r = 0.012 and p = 0.595), as
potential predictors of mother–infant bonding. A stepwise
multiple regression analysis with the forward selection
method found that HADS depression score (standardized
regression coefficient [SRC] = 0.454), HADS anxiety
score (SRC = 0.359) and parity (SRC = −0.252) weresignificantly associated with MIBS score (Table 2).

Discussion
In this study, 1116 primiparas had significantly higher
MIBS and HADS scores than 1263 multiparas one
Table 1 MIBS and HADS Scores in Primiparas and Multiparas
Variables

Table 2 Multiple Regression Analysis for the Effects of HADS
Depression and Anxiety Scores and Parity on MIBS Score

Primiparas

Multiparas(n = 1116)(n = 1263)pAge31.0 ± 4.96

33.0 ± 4.34

< 0.0001MIBS
HADS anxiety

2.89 ± 2.68
6.55 ± 4.06

1.60 ± 2.11
4.63 ± 3.41

< 0.0001< 0.0001

HADS depression

6.56 ± 3.43

5.98 ± 3.20

< 0.0001

Notes: Data are shown as the mean ± SD.
Abbreviations: HADS, Hospital Anxiety and Depression Scale; MIBS, Mother-toInfant Bonding Scale.

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HADS depression
HADS anxiety

0.449
0.522

0.454
0.359

0.003
0.015

Parity0.577−0.2520.023

Abbreviations: HADS, Hospital Anxiety and Depression Scale; MIBS, Mother-toInfant Bonding Scale; SRC, standardized regression coefficient.

month after childbirth. The Japan Environment andChildren’s Study indicated that EPDS and MIBS scores
one month after childbirth were significantly higher in
32,342 primiparas than in 44,031 multiparas.18 A metaanalysis showed that 35,023 Japanese primiparas hada significantly higher prevalence of postpartum depression
measured using EPDS than 66,983 multiparas, witha relative risk of 1.76.13 Kita et al reported that primiparity
was significantly correlated with HADS score one monthafter childbirth in 562 Japanese mothers.8 Taken together,
these findings suggest that Japanese primiparas show
poorer mother–infant bonding and worse symptoms ofanxiety and depression than multiparas in the postpartum
period. There may be some explanations for these differences. First, multiparas are likely to draw confidence fromtheir previous experience, whereas childbirth and childcare
are unknown events for primiparas.13,18,25 Second, women
who suffered bonding failure, depression or anxiety during
the peripartum period of their first birth may not want togive birth to a second child.13
Postpartum depression is a well-known risk factor for
mother–infant bonding disorder.3,18 In our multiple regression
analysis, depression had the most significant negative association with mother–infant bonding. At the second step of themultiple regression analysis, we observed a significant association between HADS anxiety score and MIBS score. Kita
et al8 also reported that HADS anxiety score was significantly
correlated with the scores of two MIBS subscales (lack ofaffection, and anger and rejection) one month after childbirthin 562 Japanese mothers. However, they used simple regression analysis. Using multiple regression analysis, Edhborg
et al9 found that the score for the State-Trait Anxiety
Inventory was inversely correlated with the score for the
Postpartum Bonding Questionnaire (PBQ) at 2–3 months
after childbirth in 674 Bangladeshi mothers. This suggeststhat there was a positive association between anxiety andmother–infant bonding. Tietz et al10 assessed depressive
symptoms using EPDS, anxiety symptoms using the Anxiety

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Cognitions Questionnaire and the Body Sensations
Questionnaire, and mother–infant bonding using PBQ in 78
German mothers at 2–8 months after childbirth. In simple
regression analyses, symptoms of both depression and anxiety
were significantly correlated with mother–infant bonding. In
a multiple regression analysis, however, the association
between symptoms of anxiety and mother–infant bonding
was not significant after controlling for the effect of depressive
symptoms. Lutkiewicz et al11 also reported similar results in
150 Polish mothers at 1–3 days after childbirth. These inconsistencies among studies may stem from differences in ethnicity, postpartum period, rating scale and statistical analysis.
However, it is important to assess the impact of both postpartum depression and anxiety on mother–infant bonding. In
our multiple regression analysis, we found the negative effectof primiparity on mother–infant bonding remained after controlling for depression and anxiety. This suggests that weshould pay attention to symptoms of both depression andanxiety especially in primiparas, who are at higher risk ofbonding disorders.
This study had some limitations. First, it was crosssectional, and therefore able to show associations between
HADS depression and anxiety scores and parity, and MIBS
score. However, we could not determine causal relationships.
Prospective studies will be needed to provide evidence forcausation. Second, our 2379 participants may not be representative of the general population of postpartum Japanesewomen. However, they were recruited from 34 obstetricinstitutions in Niigata Prefecture. Our findings that primiparas show poorer mother–infant bonding and worse depressive symptoms than multiparas are consistent with thosefrom earlier large-scale Japanese studies.13,18 We therefore
speculate that our results are unlikely to be affected bysampling bias. Third, we did not adjust for potential confounders, such as employment, education, social support,
partner relationship, attachment to own mother, and historyof mental disorders,3,4,18,40–43 because these sociodemographic data were not available.

Conclusion
Depression, anxiety and primiparity were negatively associated with mother–infant bonding one month afterchildbirth.

Abbreviations
EPDS, Edinburgh Postnatal Depression Scale; HADS,
Hospital Anxiety and Depression Scale; MIBS, Mother-3120

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to-Infant Bonding Scale; PBQ, Postpartum Bonding
Questionnaire; SRC, standardized regression coefficient.

Acknowledgments
The authors greatly appreciate the support of all participants
and staff of the participating obstetric institutions: Kameda
Daiichi Hospital, Niitsu Obstetrics and Gynecology Clinic,
Tomita Obstetrics and Gynecology Clinic, Honda Ladies
Clinic, Agano City Hospital, Chihara Clinic, Sekizuka
Clinic, Hirohashi Obstetrics and Gynecology Clinic, Niigata
Saiseikai Sanjo Hospital, Saiseikai Niigata Hospital, Itoigawa
Sogo Hospital, Niigata Prefectural Tokamachi Hospital,
Takeyama Hospital, Watanabe Kinen Clinic, Kashiwazaki
General Hospital and Medical Center, Kido Hospital,
Tachikawa Medical Center, Saintpaulia Women’s Clinic,
Nagaoka Chuo General Hospital, Arakawa Ladies Clinic,
Ueda Ladies Clinic, Uonuma Kikan Hospital, Murakami
General Hospital, Sado General Hospital, Tokunaga Ladies
Clinic, Nagaoka Red Cross Hospital, Niigata Prefectural
Shibata Hospital, Ladies Clinic Ishiguro, Angel Mother
Clinic, Joetsu General Hospital, Niigata City General
Hospital, Ojiya General Hospital, Watanabe Clinic, andNiigata University Medical and Dental Hospital. We thankJennifer Barrett, PhD, and Melissa Leffler, MBA, from Edanz
Group (https://en-author-services.edanzgroup.com/ac) for
editing a draft of this manuscript.
This work was supported by Grants-in-Aid for
Scientific Research (19K08040 to NF) from the Japan
Society for the Promotion of Science, by a grant fromthe Niigata Medical Association (to TM), and by a grantfrom the Medical Association of Niigata City (to MO).

Disclosure
Toshiyuki Someya reports grants and personal fees from
Astellas Pharma Inc., Eli Lilly Japan K.K., Mitsubishi
Tanabe Pharma Co., Mochida Pharmaceutical Co., Ltd.,MSD K.K., Novartis Pharma K.K., Otsuka PharmaceuticalCo., Ltd., Shionogi Co., Ltd., and Sumitomo Dainippon
Pharma Co., Ltd., during the conduct of the study. The
authors report no other potential conflicts of interest in thiswork.

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