Maternal-Fetal Bonding

December 1, 2023
Edition: Fall 2023
Volume: 38
Issue: 2
Article: 3

Table of Contents


A complex biological and psychological series of events commence at fertilization and continue through parturition between the preborn human organism and his or her mother, which extends far beyond the physical connection between an adult patient and contained tissue. This guideline reviews evidence in support of various aspects of this bond and its implications for care of the maternal patient.

Key Words: pregnancy, attachment, bonding, interventions


During pregnancy, an intense bond develops between mother and child. This bond is crucial for both the emotional and physical well-being of the child. The normal development of this bond progresses from knowing the child exclusively through the lens of the maternal body to later learning and appreciating who the child is as an individual.1 In early pregnancy, the only signs of the developing pregnancy are through the mother’s body. The mother develops physically visible signs such as swollen breasts and a discoloration of the cervix that make visible the developing life that is not yet large enough to be seen on his/her own. As pregnancy progresses, the child becomes more recognizable through detection of the heartbeat, distinct fetal movements, and ultrasound images. The mother is thus able to bond to a specific human being who is distinct from herself. Mother and child are then separated at time of delivery when the cord is cut. The bond that had been forming persists and allows the mother to now care for her infant outside of the womb.

The forming of this bond between the mother and child involves interactions at both the physiological and psychological levels. The physiologic interplay between mother and child via hormones and signals created and transferred through the placenta have been detailed in obstetric textbooks.2 An example of this is estrogen metabolism in which the fetal adrenal glands produce the initial precursor which is modified by the placenta and then secreted in different forms into both the maternal and fetal systems. Similarly, signals from the placenta alter maternal metabolic homeostasis to allow the mothers metabolism to preferentially transfer to the fetus the nutrients he/she needs.

Beyond hormones, there is a permanent physiologic bond created between the mother and the child through microchimerism, that is “the long term presence within an individual of a low level of cells derived from a different individual.”3 During pregnancy, fetal cells enter the mother and become established. These fetal cells can persist for decades following pregnancy.4,5 There is evidence that these fetal cells can even integrate into and influence the maternal brain.6,7 Similarly, maternal cells can enter the fetus. This has been demonstrated by detecting HLA-disparate maternal cells in immunocompetent offspring well into adult life.8 This exchange of cells occurs very early in pregnancy and is actually increased in instances of induced abortion.9,10

As the physical signs of pregnancy become translated into the mother’s psychological experience, it leads to development of a psychological bond.11 This transition into the role of mother also leads to change in self-concept.12 There is an ongoing development of maternal-fetal bonding that tends to strengthen and mature throughout the pregnancy.13,14,15,16 In early pregnancy, the mother is not able to know specific characteristics of her child and can only imagine who her child is. She must then transition from these prenatal representations of a “fantasized child” to postnatal representations of her “actual child.”17 The mother must come to know the child in the womb both through his/her connection to the mother and as a separate being with different characteristics, physical needs and emotions.18

When assessing strategies to increase maternal-fetal bonding, it is important to be able to assess the degree to which bonding is occurring. Historically, maternal-fetal attachment has been defined as “the extent to which women engage in behaviors that represent an affiliation and interaction with their unborn child.”19 In much of the literature there is an emphasis on improving maternal-fetal attachment. There is now an increasing focus on maternal-fetal “bonding” versus “attachment.” While these constructs are similar, the term bonding emphasizes the role of the mother in assuming her role of caring for the child. Attachment has historically been focused more on the child’s reliance on the parent to meet his/her needs. Thus, the literature is shifting toward a greater use of the term “bonding” while older instruments to assess these constructs have used the term “attachment.”

Specifically, there are three widely used surveys to assess the bond between mother and unborn child. In 1981, Cranley published the Maternal-Fetal Attachment Scale.19 This questionnaire focuses primarily on self-evaluation of maternal behaviors in five subscales: differentiation of self from fetus, interaction with fetus, attributing characteristics and intentions to the fetus, giving of self, and role taking. Future researchers chose to focus on more emotional assessments of bonding versus behavioral. Muller published the Prenatal Attachment Inventory which is a 29-item instrument that uses a Likert scale to assess the degree of affectionate relationship for the fetus with statements such as “I feel love for the baby.”20 The Maternal Antenatal Attachment Scale developed by Condon is a 19-item questionnaire also focused on emotional attachment.21 In contrast to the scale published by Cranley, Condon’s scale is more specifically focused on attachment to the fetus as a person versus being focused on the actions assumed within the motherhood role.

These scales have been used to correlate the degree of maternal-fetal bonding with important prenatal and postnatal outcomes. There is a positive association between maternal-fetal attachment scale scores and health practices such as smoking cessation during pregnancy.22,23,24 Multiple studies have demonstrated the link between antenatal bonding and postnatal bonding.25,26,27,28 This in turn correlates with better attunement to infant states and more accurate interpretation of infant cues29 and can predict better social affective developmental outcomes of the infant.30 For the mother, the quality of maternal–fetal bonding independently predicts postpartum depressive and anxiety symptoms.31

Clinical Q&A

Q. What Factors are Associated with Improved Maternal-fetal  Bonding?

The quality of maternal-fetal bonding is strongly associated with the quality of the mother’s other significant relationships. In one study, the most important determinant of maternal-fetal attachment identified was perceived social support.32 In another, the quality of the maternal-fetal relationship was best predicted by the romantic caregiving responsiveness to her partner and the woman’s own psychological health.33

Q. What Factors Increase Risk for Poor Maternal-fetal Bonding?

The capacity of a mother to successfully bond with her preborn child can be influenced by a history of interpersonal trauma or unhealthy relationships in her own life.34,35,36 These traumas can lead to early maladaptive schemas and insecure attachment styles within the mother that impair the mother’s ability to bond with her child.37,38,39 Depression, anxiety, and poor social support are all associated with poor maternal-fetal attachment.32,40,41,42,43

In addition, teenagers are at a particularly high risk for impaired bonding. Teenagers tend to develop attachments more slowly than adults do. In one cohort, the risk of persistent poor bonding remains elevated in teenagers with low first trimester attachment scores and history of pregnancy termination.44

Q. What Interventions have been shown to Increase Maternal-fetal Bonding?

For women at risk of poor maternal-fetal bonding, there are many suggestions for strengthening this relationship. Given the variable reasons mothers may have poor bonding, there is unlikely to be a standardized approach. Instead, interventions should be tailored to the underlying risks for poor bonding.45

Multiple studies have assessed the role of educational interventions with high success rates. Topics have included physiology of pregnancy and childbirth, awareness of the feelings and perceptions of the embryo, the concept of attachment, attachment behavior, control of anxiety and negative thoughts, patterns of proper sleep, exercise and nutrition during pregnancy, and relaxation training.46,47,48,49 These educational programs have been linked to improvement in infant mental health variables from birth all the way to the first year.46,50

Simple interventions to increase awareness of fetal characteristics at prenatal visits may also impact bonding. When midwives explain the fetal position by taking the hand of each participant and touching the head or the buttocks of the fetus, it has been correlated with increased maternal awareness of fetal position and improved maternal-fetal attachment.51 A randomized controlled trial showed that women who were taught to do fetal kick counts at 28-32 weeks gestation had significantly higher maternal-fetal attachment scores after 1 month of counting.52 A more recent trial found conflicting results about the impact of fetal movement counting, which was likely due to baseline characteristics of the populations studied.53

Ultrasound is likely to be more beneficial in the early stages of maternal-fetal bonding before a clear mental construct of the fetus as a person is developed. In the mid-trimester, a 3D ultrasound appears to be more impactful for helping to develop this construct than a 2D ultrasound and positively impacts bonding.54 The impact of the ultrasound seems to be mediated by the clarity of the images.55 By the time a woman reaches the third trimester, ultrasound appears to be beneficial only for select mothers, such as those with high levels of depressive symptoms at baseline.56

Finally, interventions that improve maternal health and wellbeing can strengthen the mother’s ability to bond with her fetus. A randomized controlled trial demonstrated that listening to music during  pregnancy is linked to lower psychosocial stress and increased maternal-fetal bonding.57 Another program focused on teaching women to sing lullabies also found it was a positive experience that allowed the mothers to express complex emotions they were experiencing.58 A composite intervention that included dancing and singing sessions resulted in higher prenatal attachment scores than controls who did not have prenatal courses.48 Deliberate involvement in a Qi exercise group resulted in higher post-test maternal-fetal interaction scores.59 A pilot study showed a 2-week program of prompting mindfulness behaviors via a text messaging system enhanced maternal-fetal bonding.60

Q. What is the Impact of Prenatal Genetic Testing on Maternal-fetal Bonding?

There are concerns that there are social pressures to conform with prenatal testing which may unintentionally burden expectant mothers.61 After completing an exploratory analysis, sociologist Rothman concluded that if the decision to continue pregnancy rests on the results of prenatal testing, it creates a state of “tentative pregnancy.” That is, the state of total attachment normally demonstrated early in pregnancy is delayed. Instead of the child being seen as good by nature of his or her existence, the child must be deemed “worthy” of surviving depending on the test results. The mother delays attachment early in pregnancy and then must try to catch-up after she decides to continue pregnancy.1

Further studies have provided evidence that the decision to have prenatal screening and/or testing delays, if not permanently impairs, maternal-fetal bonding.62 In a qualitative study of first trimester screening in Denmark, most patients did look forward to having an ultrasound but said they would terminate if abnormal.63 Having a quad screen can delay the developmental trajectory of prenatal attachment even if low risk results are obtained.64 In a separate observational study, mothers who were highly informed about genetic testing were again found to have delayed attachment to their fetuses but were able to catch up after results were received.65 Expert testimony to the Senate Subcommittee on Science, Technology, and Space of the Committee on Commerce, Science, and Transportation summarized these studies and clinical experience with the concern that the anxiety and lack of joy with prenatal diagnoses attaches a stigma to the child and causes “irreparable damage. . . to the family bond.”66 Though data are limited, it is likely that all women who wrestle with the decision of if they should continue a pregnancy are at risk for similar challenges to impaired early bonding.

Q. What is the Impact of Previous Pregnancy Loss on Maternal-fetal Bonding?

There is mixed data concerning the impact of previous pregnancy loss on maternal-fetal bonding. A longitudinal study demonstrated that a history of miscarriage decreased maternal-fetal attachment in the first trimester, but those differences resolved by the third trimester.67 Among Iranian women, those who had a history of pregnancy loss scored lower on behaviors related to differentiation of self from fetus (items like “I can imagine myself taking care of the baby” and “I picture myself feeding the baby”) but they scored the same on interactions with the fetus, attribution of characteristics to the fetus, giving of self, and role-taking.68 However, in another cross-sectional study, researchers were unable to identify significant Prenatal Attachment Inventory score differences between parents with and without a previous pregnancy loss.69

Summary of Recommendations and Conclusion

The following recommendations are based on good and consistent scientific evidence (Level A):

  1. Quality of maternal-fetal bonding is linked to postnatal attachment and indicators of infant psychological wellbeing.
  2. Mothers with insecure attachments and interpersonal trauma are at increased risk for poor maternal-fetal bonding.
  3. Educational interventions can improve maternal-fetal bonding in at-risk mothers.

The following recommendations are based on limited and inconsistent scientific evidence (Level B):

  1. In at-risk women, ultrasound may have a role in improving maternal-fetal bonding.
  2. Prenatal diagnostic testing and the resultant “tentative pregnancy” can negatively impact maternal-fetal bonding.

The following recommendations are based primarily on consensus and expert opinion (Level C):

 1) An emphasis should be placed on maternal-fetal “bonding” versus “attachment” because this better reflects the directional relationship of the mother caring for the child and learning to meet his or her needs.



Rothman, B.K., The Tentative Pregnancy: Prenatal Diagnosis and the Future of Motherhood. 1986, New York: Viking.


Charles J. Lockwood, T.M., Joshua Copel, Robert M Silver, & Robert Resnik, Creasy and Resnik’s Maternal-Fetal Medicine: Principles and Practice,. 8 ed. 2019, Philedelphia, PA: Elsevier.


Boyon, C., et al., Fetal microchimerism: benevolence or malevolence for the mother? Eur J Obstet Gynecol Reprod Biol, 2011. 158(2): p. 148-52.


Bianchi, D.W., et al., Forever Connected: The Lifelong Biological Consequences of Fetomaternal and Maternofetal Microchimerism. Clin Chem, 2021. 67(2): p. 351-362.


O’Donoghue, K., et al., Microchimerism in female bone marrow and bone decades after fetal mesenchymal stem-cell trafficking in pregnancy. Lancet, 2004. 364(9429): p. 179-82.


Zeng, X.X., et al., Pregnancy-associated progenitor cells differentiate and mature into neurons in the maternal brain. Stem Cells Dev, 2010. 19(12): p. 1819-30.


Tan, X.W., et al., Fetal microchimerism in the maternal mouse brain: a novel population of fetal progenitor or stem cells able to cross the blood-brain barrier? Stem Cells, 2005. 23(10): p. 1443-52.


Maloney, S., et al., Microchimerism of maternal origin persists into adult life. J Clin Invest, 1999. 104(1): p. 41-7.


Wataganara, T., et al., Cell-free fetal DNA levels in maternal plasma after elective first-trimester termination of pregnancy. Fertil Steril, 2004. 81(3): p. 638-44.


Yan, Z., et al., Male microchimerism in women without sons: quantitative assessment and correlation with pregnancy history. Am J Med, 2005. 118(8): p. 899-906.


Uriko, K., Semiotic Regulation in the Construction of Maternal Bond: From Body Experience to the Semiotic Field. Integr Psychol Behav Sci, 2018. 52(4): p. 672-685.


Darvill, R., H. Skirton, and P. Farrand, Psychological factors that impact on women’s experiences of first-time motherhood: a qualitative study of the transition. Midwifery, 2010. 26(3): p. 357-66.


Righetti, P.L., et al., Maternal/paternal antenatal attachment and fourth-dimensional ultrasound technique: a preliminary report. Br J Psychol, 2005. 96(Pt 1): p. 129-37.


Rossen, L., et al., Maternal Bonding through Pregnancy and Postnatal: Findings from an Australian Longitudinal Study. Am J Perinatol, 2017. 34(8): p. 808-817.


Grace, J.T., Development of maternal-fetal attachment during pregnancy. Nurs Res, 1989. 38(4): p. 228-32.


Cˇe·snaite·, G., et al., Factors affecting the maternal-foetal relationship. Acta Med Litu, 2019.
26(2): p. 118-124.


Theran, S.A., et al., Stability and change in mothers’ internal representations of their infants over time. Attach Hum Dev, 2005. 7(3): p. 253-68.


Shieh, C., M. Kravitz, and H.H. Wang, What do we know about maternal-fetal attachment? Kaohsiung J Med Sci, 2001. 17(9): p. 448-54.


Cranley, M.S., Development of a tool for the measurement of maternal attachment during pregnancy. Nurs Res, 1981. 30(5): p. 281-4.


Muller, M.E., Development of the Prenatal Attachment Inventory. West J Nurs Res, 1993.
15(2): p. 199-211; discussion 211-5.


Condon, J.T., The assessment of antenatal emotional attachment: development of a questionnaire instrument. Br J Med Psychol, 1993. 66 ( Pt 2): p. 167-83.


Lindgren, K., Relationships among maternal-fetal attachment, prenatal depression, and health practices in pregnancy. Res Nurs Health, 2001. 24(3): p. 203-17.


Massey, S.H., et al., Maternal-fetal attachment differentiates patterns of prenatal smoking and exposure. Addict Behav, 2015. 45: p. 51-6.


Jussila, H., et al., The association of maternal-fetal attachment with smoking and smoking cessation during pregnancy in The FinnBrain Birth Cohort Study. BMC Pregnancy Childbirth, 2020. 20(1): p. 741.


Hadian, T., et al., Relationship of health practices with depression and maternal-fetal attachment in adolescent pregnant women: A prospective study. Arch Psychiatr Nurs, 2021. 35(5): p. 465-471.


Zdolska-Wawrzkiewicz, A., et al., The Dynamics of Becoming a Mother during Pregnancy and After Childbirth. Int J Environ Res Public Health, 2019. 17(1).


Rossen, L., et al., Predictors of postnatal mother-infant bonding: the role of antenatal bonding, maternal substance use and mental health. Arch Womens Ment Health, 2016. 19(4): p. 609-22.


Siddiqui, A. and B. Hägglöf, Does maternal prenatal attachment predict postnatal mother-infant interaction? Early Hum Dev, 2000. 59(1): p. 13-25.


McMahon, C., et al., Maternal Mind-Mindedness: Relations with Maternal-Fetal Attachment and Stability in the First Two Years of Life: Findings from an Australian Prospective Study. Infant Ment Health J, 2016. 37(1): p. 17-28.


Le Bas, G., et al., The Role of Antenatal and Postnatal Maternal Bonding in Infant Development. J Am Acad Child Adolesc Psychiatry, 2021.


Petri, E., et al., Maternal-foetal attachment independently predicts the quality of maternal-infant bonding and post-partum psychopathology. J Matern Fetal Neonatal Med, 2018.
31(23): p. 3153-3159.


Ertmann, R.K., et al., What factors are most important for the development of the maternal-fetal relationship? A prospective study among pregnant women in Danish general practice. BMC Psychol, 2021. 9(1): p. 2.


Walsh, J., E.G. Hepper, and B.J. Marshall, Investigating attachment, caregiving, and mental health: a model of maternal-fetal relationships. BMC Pregnancy Childbirth, 2014. 14: p. 383.


Rusanen, E., et al., The significance of supportive and undermining elements in the maternal representations of an unborn baby. J Reprod Infant Psychol, 2018. 36(3): p. 261-275.


Schwerdtfeger, K.L. and B.S. Goff, Intergenerational transmission of trauma: exploring mother-infant prenatal attachment. J Trauma Stress, 2007. 20(1): p. 39-51.


Ramsdell, E.L. and R.L. Brock, Interparental Relationship Quality During Pregnancy: Implications for Early Parent-Infant Bonding and Infant Socioemotional Development. Fam Process, 2021. 60(3): p. 966-983.


Nordahl, D., et al., Early maladaptive schemas as predictors of maternal bonding to the unborn child. BMC Psychol, 2019. 7(1): p. 23.


Alhusen, J.L., M.J. Hayat, and D. Gross, A longitudinal study of maternal attachment and infant developmental outcomes. Arch Womens Ment Health, 2013. 16(6): p. 521-9.


Tani, F., V. Castagna, and L. Ponti, Women who had positive relationships with their own mothers reported good attachments to their first child before and after birth. Acta Paediatr, 2018. 107(4): p. 633-637.


Gobel, A., et al., The association between maternal-fetal bonding and prenatal anxiety:
An explanatory analysis and systematic review. J Affect Disord, 2018. 239: p. 313-327.


McFarland, J., et al., Major depressive disorder during pregnancy and emotional attachment to the fetus. Arch Womens Ment Health, 2011. 14(5): p. 425-34.


Zhang, L., et al., The mediating role of prenatal depression in adult attachment and maternal-fetal attachment in primigravida in the third trimester. BMC Pregnancy Childbirth, 2021.
21(1): p. 307.


Condon, J.T. and C. Corkindale, The correlates of antenatal attachment in pregnant women. Br J Med Psychol, 1997. 70 ( Pt 4): p. 359-72.


Rowe, H.J., et al., The growth of maternal-fetal emotional attachment in pregnant adolescents: a prospective cohort study. J Pediatr Adolesc Gynecol, 2013. 26(6): p. 327-33.


Rohder, K., et al., Maternal-fetal bonding among pregnant women at psychosocial risk: The roles of adult attachment style, prenatal parental reflective functioning, and depressive symptoms. PLoS One, 2020. 15(9): p. e0239208.


Akbarzadeh, M., et al., Teaching attachment behaviors to pregnant women: a randomized controlled trial of effects on infant mental health from birth to the age of three months. Ann Saudi Med, 2016. 36(3): p. 175-83.


Toosi, M., M. Akbarzadeh, and Z. Ghaemi, The Effect of Relaxation on Mother’s Anxiety and Maternal-Fetal Attachment in Primiparous IVF Mothers. J Natl Med Assoc, 2017. 109(3): p. 164-171.


Bellieni, C.V., et al., Is prenatal bonding enhanced by prenatal education courses? Minerva Ginecol, 2007. 59(2): p. 125-9.


Ekrami, F., et al., Effect of counseling on maternal-fetal attachment in women with unplanned pregnancy: a randomized controlled trial. J Reprod Infant Psychol, 2020. 38(2): p. 151-165.


Bryan, A.A., Enhancing parent-child interaction with a prenatal couple intervention. MCN Am J Matern Child Nurs, 2000. 25(3): p. 139-44; quiz 145.


Nishikawa, M. and H. Sakakibara, Effect of nursing intervention program using abdominal palpation of Leopold’s maneuvers on maternal-fetal attachment. Reprod Health, 2013. 10: p. 12.


Mikhail, M.S., et al., The effect of fetal movement counting on maternal attachment to fetus. Am J Obstet Gynecol, 1991. 165(4 Pt 1): p. 988-91.


Saastad, E., et al., Fetal movement counting--effects on maternal-fetal attachment: a multicenter randomized controlled trial. Birth, 2011. 38(4): p. 282-93.


Ji, E.K., et al., Effects of ultrasound on maternal-fetal bonding: a comparison of two- and three-dimensional imaging. Ultrasound Obstet Gynecol, 2005. 25(5): p. 473-7.


de Jong-Pleij, E.A., et al., Three-dimensional ultrasound and maternal bonding, a third trimester study and a review. Prenat Diagn, 2013. 33(1): p. 81-8.


Westerneng, M., et al., The effect of offering a third-trimester routine ultrasound on pregnancy-specific anxiety and mother-to-infant bonding in low-risk women: A pragmatic cluster-randomized controlled trial. Birth, 2022. 49(1): p. 61-70.


Chang, H.C., et al., The effects of music listening on psychosocial stress and maternal-fetal attachment during pregnancy. Complement Ther Med, 2015. 23(4): p. 509-15.


Carolan, M., et al., Experiences of pregnant women attending a lullaby programme in Limerick, Ireland: a qualitative study. Midwifery, 2012. 28(3): p. 321-8.


Ji, E.S. and H.R. Han, The effects of Qi exercise on maternal/fetal interaction and maternal well-being during pregnancy. J Obstet Gynecol Neonatal Nurs, 2010. 39(3): p. 310-8.


Shreffler, K.M., et al., Effect of a mindfulness-based pilot intervention on maternal-fetal bonding. Int J Womens Health, 2019. 11: p. 377-380.


Tymstra, T., Prenatal diagnosis, prenatal screening, and the rise of the tentative pregnancy. Int J Technol Assess Health Care, 1991. 7(4): p. 509-16.


Heidrich, S.M. and M.S. Cranley, Effect of fetal movement, ultrasound scans, and amniocentesis on maternal-fetal attachment. Nurs Res, 1989. 38(2): p. 81-4.


Lou, S., et al., Experiences and expectations in the first trimester of pregnancy: a qualitative study. Health Expect, 2017. 20(6): p. 1320-1329.


Lawson, K.L. and S.I. Turriff-Jonasson, Maternal serum screening and psychosocial attachment to pregnancy. J Psychosom Res, 2006. 60(4): p. 371-8.


Rowe, H., J. Fisher, and J. Quinlivan, Women who are well informed about prenatal genetic screening delay emotional attachment to their fetus. J Psychosom Obstet Gynaecol, 2009.
30(1): p. 34-41.


Prenatal Genetic Testing Technology: Science, Policy, and Ethics, in Subcommittee on Science, Technology, and Space of the Committee on Commerce, Science, and Transportation 2013, US Government Printing Office: Washington.


Tsartsara, E. and M.P. Johnson, The impact of miscarriage on women’s pregnancy-specific anxiety and feelings of prenatal maternal-fetal attachment during the course of a subsequent pregnancy: an exploratory follow-up study. J Psychosom Obstet Gynaecol, 2006. 27(3): p. 17382.


Mehran, P., et al., History of perinatal loss and maternal-fetal attachment behaviors. Women Birth, 2013. 26(3): p. 185-9.


Armstrong, D.S., Emotional distress and prenatal attachment in pregnancy after perinatal loss. J Nurs Scholarsh, 2002. 34(4): p. 339-45.

About the Authors

Affiliation: The American Association of Pro-Life Obstetricians and Gynecologists (AAPLOG). Affiliation for Dr. Barr: Ascension Medical Group.