ORİJİNAL MAKALE / ORIGINAL ARTICLE

Balıkesir Sağlık Bilimleri Dergisi / BAUN Sağ Bil Derg

Balıkesir Health Sciences Journal / BAUN Health Sci J
ISSN: 2146-9601- e ISSN: 2147-2238
Doi: https://doi.org/10.53424/balikesirsbd.1029908

The Correlation Between Mother-Infant Bonding and Postpartum Depression in

Women with A History of Infertility
Elif ÖZDEMİR 1, Sena KAPLAN 2, Sibel KÜÇÜK 2
1
Ankara University, Ibni Sina Hospital, Nursing Department
2
Ankara Yildirim Beyazit University, Faculty of Health Sciences Nursing Department

Geliş Tarihi / Received: 29.11.2021, Kabul Tarihi / Accepted: 06.06.2022

ABSTRACT
Objective: This study investigated the correlation between mother-infant bonding and postpartum depression in women with
a history of infertility. Methods: The sample consisted of 169 women divided into two: infertile group (n=56) and fertile
group (n=112). Data were collected using a descriptive information questionnaire, the Edinburgh Postnatal Depression Scale
(EPDS), and the Mother-to-Infant Bonding Scale (MIBS). Results: The fertile and infertile groups had a mean age of
28.95±3.38 and 36.55±3.55, respectively (p=0.001). The infertile group had a higher mean MIBS score (3.73±2.91) than the
fertile group (1.50±1.29) (p=0.001). However, there was no significant difference in EPDS scores between the two groups
(p>0.05). Moreover, there was a positive correlation between MIBS and EPDS score in the fertile group (r= 0.354, p=0.001),
suggesting that the higher the risk for postpartum depression, the lower the mother-infant bonding. There was no correlation
between MIBS and EPDS score in the infertile group (p>0.05). Conclusion: Future studies should recruit larger samples of
infertile women with cultural and ethnic diversity and take confounding factors into account to investigate the relationship
between postpartum depression and mother-infant bonding.
Keywords: Infertility History, Postpartum Depression, Mother-Infant Bonding.

İnfertilite Hikayesi Olan Kadınlarda Anne Bebek Bağlanması ve Postpartum

Depresyon Arasındaki İlişki
ÖZ
Amaç: Bu çalışmada infertilite hikayesi olan kadınlarda anne bebek bağlanması ve postpartum depresyon arasındaki ilişki
incelenmiştir. Gereç ve Yöntem: Çalışmanın örneklemini infertil grup (n=56) ve fertil grup (n=112) olmak üzere toplam
169 kadın oluşturmuştur. Veriler Tanımlayıcı Bilgi Formu, Edinburg Postpartum Depresyon Skalası (EPDS) ve Anne-Bebek
Bağlanma Ölçeği (ABBÖ) kullanılarak toplanmıştır. Bulgular: Fertil ve infertil grupların yaş ortalaması sırasıyla
28.95±3.38 ve 36.55±3.55 idi (p=0.001). İnfertil grupta ABBÖ puan ortalamasının (3.73±2.91), fertil gruba göre daha yüksek
(1.50±1.29) olduğu belirlenmiştir (p=0.001). Ancak iki grup arasında EPDS ortalama puanları yönünden anlamlı bir fark
bulunmamıştır (p>0.05). Bunun yanı sıra, fertil grupta ABBÖ ve EPDS ortalama puanları arasında pozitif bir ilişki olduğu
belirlenmiştir (r=0.354, p=0.001). Bu bulgu doğum sonrası depresyon riski ne kadar yüksek ise anne ve bebek bağlanma
düzeyinin o kadar düşük olduğunu göstermiştir. İnfertil grupta ise ABBÖ ve EPDS ortala puanları arasında ise bir ilişki
belirlenmemiştir (p>0.05). Sonuç: Kültürel ve etnik çeşitliliğin bulunduğu daha büyük gruplarda infertil hikayesi olan
kadınlarda olası karıştırıcı faktörlerin hesaba katılarak, postpartum depresyon ve anne bebek bağlanma ilişkinin
değerlendirildiği çalışmalara ihtiyaç bulunmaktadır.
Anahtar Kelimeler: İnfertilite Öyküsü, Postpartum Depresyon, Anne-Bebek Bağlanması.

Sorumlu Yazar / Corresponding Author: Sena KAPLAN, Ankara Yıldırım Beyazıt University, Faculty of Health Sciences,
Nursing Department, Ankara, Türkiye.
E-mail: [email protected]

Bu makaleye atıf yapmak için / Cite this article: Özdemir, E., Kaplan, S., & Küçük, S. (2022). The correlation between
mother-infant bonding and postpartum depression in women with a history of infertility. BAUN Health Sci J, 11(3), 403-
410. https://doi.org/10.53424/balikesirsbd.1029908

BAUN Health Sci J, OPEN ACCESS https://dergipark.org.tr/tr/pub/balikesirsbd

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License

BAUN Sağ Bil Derg 2022; 11(3): 403-410 403

Özdemir et al. Infertility and Postpartum Depression

INTRODUCTION who conceive spontaneously and those who conceive

Infertility is a complicated crisis that adversely affects after infertility treatment?
social and sex life, marital relations, emotional well-
being, and plans (Akyuz et al., 2010; Sahin & Gursoy, MATERIALS AND METHODS
2020). Women, especially in traditional societies, are Population and sampling
valued and respected only when they bear children. This comparative descriptive study was carried out
Giving birth is also considered a sign of sexual potency between September 2019 and June 2020 at a Gynecology
(Sahin & Gursoy, 2020). Couples diagnosed with Training and Research Hospital in Ankara. Prior and
infertility experience psychosocial problems (Akyuz et post-hoc power analysis were both performed based on
al., 2010; Hess et al., 2018). Besides, infertility diagnosis two independent groups. Expected Cohens' f value for
and treatment are a long, painful, and financially effect size was 0.2 which is considered as small effect
burdensome process (Akyuz et al., 2010). Research size. For a type I error of 0.05 and an effect size of 0.2
shows that women with a history of infertility are more with a minimum required power of 80%, the estimated
probably to experience depression, anxiety, isolation, total sample size was 152, including the infertile group
and loss of control than fertile women (Hess et al., 2018; (IG, n=51) and the fertile group (FG, n=102).
Safaei Nezhad et al., 2018). Women who conceive after Considering 10% sample loss, a total of 168 people, 56
infertility treatment experience more anxiety and in the infertile group and 112 in the fertile group, were
depression than those who conceive spontaneously included in the study. Power analysis was performed
(Akyuz et al., 2010; Olshansky & Sereika, 2005). again at the end of the study based on mean MIBS scores
Postpartum is a period of physiological changes and and standard deviations. Post-hoc effect size of the study
adaptation to new roles. The transition to motherhood was calculated as 0.92 and post-hoc power 95%. For
can be stressful. It is more challenging for women with a Power analyses G-power package version 3.1.9.2 was
history of infertility than for those who conceive used.
spontaneously (Akyuz et al., 2010). Research shows that Criteria for inclusion
women with a history of infertility who experience The inclusion criteria were as follows: (1) literate, (2)
pregnancy-specific anxiety and depression are more Turkish speakers, (3) carrying one fetus, (4) giving birth
vulnerable to postpartum depression (PPD) (Akyuz et al., by C-section, (5) being primiparous, (6) no having
2010; Olshansky & Sereika, 2005). PPD is defined as “a pregnancy-related complication (preeclampsia,
major depressive episode that can manifest itself during gestational diabetes, bleeding, epilepsy, etc.); (7) no
the first four weeks after giving birth and is characterized congenital malformation in the infant, (8) no mental
by dramatic mood swings that can occur up to one year health problems (depression, anxiety, severe
later” (American Psychiatric Association, 2021). The psychosocial problems, etc.), (9) filling out the forms
worldwide prevalence of PPD is 5.5% to 25% completely, and (10) voluntary.
(Soderquist et al., 2009). The prevalence of PPD in We pre-interviewed 250 women until we reached the
women with a history of infertility is 12.9% to 25% (Lee target sample size. A total of 168 women met the
et al., 2011; Lynch & Prasad, 2014). inclusion criteria [FG (n=112) and IG (n=56)]. The
PPD adversely affects mother-infant bonding (MIB) remaining 82 women were excluded because they could
(Sliwerski et al., 2020; Forman et al., 2007). Mothers not speak Turkish (n=13), were illiterate (n=19),
with depression will probably suffer more from stress, multiparous (n=25), or had a vaginal delivery (n=22).
view their children in a more negative light, and have a Twelve participants did not turn up, and therefore, the
less intense relationship with and less secure attachment final sample consisted of 156 women in the second stage
with them than those without depression (Forman et al., [FG (n=104) and IG (n=52)].
2007). However, there is no published research Data collection tools
investigating the correlation between MIB and PPD in The Descriptive Information Questionnaire-1 (DIQ-1)
women with a history of infertility. MIB disorders consisted of 15 items on the sociodemographic and
deteriorate mother-child relationships in the long term obstetric characteristics of women who conceived
(Lehning et al., 2019). Therefore, it is essential to spontaneously (Akyuz et al. 2010; Lee et al. 2011).
identify the risks affecting MIB quality early and support The Descriptive Information Questionnaire-2 (DIQ-2)
mothers with a history of infertility. consisted of 20 items on the sociodemographic and
The research questions were as follows: obstetric characteristics of women who conceived after
Q.1. Is there a significant difference in Mother-to-Infant ART (Akyuz et al., 2010; Lee et al., 2011; Lynch &
Bonding Scale (MIBS) scores between women who Parasad, 2014).
conceive spontaneously and those who conceive after The Edinburgh Postnatal Depression Scale (EPDS) was
infertility treatment? developed by Cox et al. (1987) to evaluate depressive
Q.2. Is there a significant difference in Edinburgh symptoms. The EPDS was adapted to Turkish by
Postnatal Depression Scale (EPDS) scores between Engindeniz et al. (1996). It consists of 10 items scored
women who conceive spontaneously and those who on a four-point Likert-type scale (min=0, max=30).
conceive after infertility treatment? Q.3. Is there a Higher scores indicate more severe symptoms of
correlation between MIBS and EPDS scores in women depression. Engindeniz et al. (1996) reported the
Cronbach’s alpha as 0.79, 0.83 in this study.

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Özdemir et al. Infertility and Postpartum Depression

The Mother-to-Infant Bonding Scale (MIBS) was spontaneously and those who got pregnant after ART (in
developed by Taylor et al. (2005) to identify the level of vitro fertilization, artificial insemination, etc.). The
maternal bonding. The MIBS was adapted to Turkish by fertile group (FG) consisted of women who conceived
Karakulak et al. (2007). It consists of eight items scored spontaneously, while the infertile group (IG) consisted of
on a scale of 0 to 3. The total score ranges from 0 to 24, those who got pregnant after ART. The FG participants
with higher scores indicating lower MIB. The scale has completed the DIQ-1 and EPDS, while the IF
a Cronbach’s alpha of 0.71 in the 12 th week postpartum participants completed the DIQ-2 and EPDS. We also
(Taylor et al., 2005) and 0.68.3 in the 8 th-12th week received permission from participants to log their contact
postpartum (Karakulak et al., 2007). The Cronbach’s details.
alpha was 0.70 (in the 8th-12th week postpartum) in this Second, we contacted all participants by phone to set
study. dates for their visits to the Newborn and Child Outpatient
Procedure Clinic for routine newborn follow-up in the eighth-
The research consisted of two stages. First, we checked twelfth week postpartum. Both groups completed the
the files of all women admitted to the obstetric outpatient MIBS (Figure 1).
clinic for routine follow-up in the fourth-sixth weeks
postpartum and determined those who got pregnant

Assessing for eligibility (n=250)

Fourth to sixth week postpartum

Excluded (n=82)
• Speaking a language other than
Turkish (n=13)
• Multiparous (n=28)
• Vaginal delivery (22)
• Illiterate (n=19)

Sampling (n=168)

Fertile group (n=112) Infertile group (n=56)

Completing DIQ and EPDS Completing DIQ and EPDS

Not showing up for Not showing up for

follow-up (n=8) follow-up (n=4)

Eighth to twelfth week

postpartum

Fertile group (n=104) Infertile group (n=52)

Completing MIBS Completing MIBS

End of study (n=156)

Figure 1. Flow diagram.

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 Özdemir et al. Infertility and Postpartum Depression

Data analysis DISCUSSION

Data were analyzed using the Statistical Package for This study examined the correlation between MIB and
Social Sciences (SPSS, v. 23.0) at a significance level of PPD in women who conceived spontaneously and those
0.05. Percentage, median (minimum, maximum), mean who conceived after infertility treatment. Postpartum
(standard deviation), chi-square, and Mann-Whitney U depression (PPD) was assessed using the EPDS in the
test were used for analysis. Normality test of the study fourth to sixth week postpartum, while mother-infant
was checked using the Shapiro-Wilk test. The Spearman bonding (MIB) was assessed using the MIBS in the
correlation was used to determine the correlation eighth to twelfth week postpartum. This study showed
between scale scores. that the IG participants had higher levels of MIB than
Ethical considerations their FG counterparts (p<0.05). There was no
The study was approved by an Ethics Committee significant difference in EPPD scores between the
(approval date/number: February 23, 2018/51). infertile and fertile groups in our study (p0.05). We
Permission was obtained from the hospital management. also found a positive correlation between EPDS and
Prior to participation, all women were informed of the MIBS scores in the fertile group. It is noteworthy that
research purpose, confidentiality, and their right to there was no correlation between EPDS and MIBS
withdraw. Informed consent (including permission to be scores in the infertile group.
interviewed) was obtained from those who agreed to The average age of marriage and childbearing is rising
participate according to the guidelines presented in the worldwide. Fertility naturally declines as women get
Declaration of Helsinki. older (Haliloğlu et al., 2014), and infertile women are
more likely to enter into marriage later than fertile
RESULTS women (Akyüz et al., 2010). In the last two decades,
Demographic characteristics Turkey has witnessed an increase in the age of marriage
Table 1 shows the socio-demographic and obstetrics and fertility because women today are participating in
characteristics of the participants. The fertile group was social and economic life and pursuing their career goals
younger (28.95±3.38) than the infertile group more actively than before. For women, the age of
(36.55±3.55) (p=0.001). The mean age of marriage was marriage increased from 22 in 2000 to 25 in 2019.
significantly lower in the fertile group (24.49 ± 2.48) Similarly, the age of childbearing increased from 26 in
than in the infertile group (28.00±2.66 years) 2000 to 29 in 2019 (TÜİK, 2019). Our results showed
(p=0.001). Thirty-eight FG (36.5%) and 24 IG (46.2%) that the age of childbearing and marriage among fertile
participants breastfed their babies within the first hour women was close to the national average but lower than
postpartum. The difference was statistically significant that in women with a history of infertility. It is thought
(p<0.05). The majority of FG participants (60.0%) that there is relationship between fertility and maternal
received support from their relatives and friends, while age.
slightly more than half the IG participants (53.9%) Infertility diagnosis has adverse psychosocial impacts on
received support from their spouses/partners in the first couples (Akyuz et al., 2010; Hess et al., 2018). Besides,
four weeks postpartum (p<0.05). The two groups were infertility diagnosis and treatment is a long, painful, and
demographically similar in terms of education, family financially burdensome process (Akyuz et al., 2010).
type, employment, and satisfaction with the newborn’s Women receiving infertility treatment are extremely
sex (p>0.05). Though not shown in Table 1, the IG worried about the process and treatment outcomes
participants had a mean infertility treatment of 4.0±1.83 (Hasanpoor-Azghdy et al., 2014). Infertile women have
years (min=1-max=10). Thirty-four percent of the difficulty adapting to the postpartum period and
cases were female infertility due to female-related assuming parenting roles due to past experiences and fear
problems. of losing their babies (Ranjbar et al., 2015). There are
Distribution of scale scores contradicting results regarding the prevalence of PPD
The infertile group (1.50±1.29) had a lower mean among women who conceive spontaneously or after
MIBS score than the fertile group (3.73±2.91) in the infertility treatment. Ross et al. shows that women who
eighth to twelfth week postpartum (p=0.001). This conceive after infertility treatment have a higher
result showed that the IG participants had higher levels prevalence of PPD than those who
of MIB than their FG counterparts. There was no conceive spontaneously. On the other hand, some other
significant difference in EPDS scores between the studies report similar rates of PPD in the two groups
infertile (12.01±3.39) and fertile groups (13.45±6.31) (Akyuz et al., 2010; Gressier et al., 2015). There was no
in the fourth to sixth week postpartum (p>0.05) (Table significant difference in EPPD scores between the
2). infertile and fertile groups in our study (p0.05). Small et
There was a positive correlation between EPDS and al. (2003) argue that women deprived of social support in
MIBS scores in the fertile group (r=0.354, p=0.001), the postpartum period are more likely to experience
suggesting that the higher the risk for PDD, the lower psychosocial problems and PPD. In our study, the
the MIB. There was no correlation between EPDS and infertile and fertile groups had similar levels of
MIBS scores in the infertile group (p>0.05) (Table 3). depression, which may be because most women in both
groups received support from their spouses/partners or
their relatives/friends in the postpartum period.

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 Özdemir et al. Infertility and Postpartum Depression

It was determined that women in the infertile group (2012) found that infertile Turkish women described
received more support from their spousal/partners, and themselves as “dying trees” and “barren land.” Women
women in the fertile group received support from their stated that they were the subject of peer pressure and
relatives and friends in this study. According to were bombarded with questions about having kids.
Hasanpoor-Azghdy et al. (2014), infertile women keep Therefore, most couples with a history of infertility do
their diagnosis and treatment to themselves. Akizuki and not share their story with family or friends (Koçyiğit,
Kai (2008) maintain that spousal/partner support is 2012). In our study, women in the infertile group received
essential for infertile women to become less dependent support primarily from their spouses/partners. This result
on others. In Turkish society, bearing children results in also suggests that infertile couples choose to go through
strong social approval and respect and is considered a the diagnosis and treatment process by themselves
sign of sexual potency (Sahin & Gursoy, 2020). Koçyiğit without sharing it with their family and friends.

Table 1. Socio-demographic and obstetrics characteristics (n=156).

Fertile group Infertile group

(n=104) (n=52)
Test value p
Characteristics n % n %

Age, y, x̄±SD 28.95±3.38 36.55 ± 3.55 5.078a 0.001**

Age of marriage, y, x̄±SD 24.49±2.48 28.00 ± 2.66 6.877a 0.001**

Educational status
0.667
<High school 21 20.2 9 17.3 0.186b
≥High school 83 79.8 43 82.7

Employment status
Employed 55 52.9 25 48.1 0.321b 0.571
Unemployed 49 47.1 27 51.9
Family type
0.110
Nuclear 92 88.5 41 78.8 2.550b
Extended 12 11.5 11 21.2
First breastfeeding
9.625b 0.008*
Within the first hour 38 36.5 24 46.2
First 1-2 hours 49 47.1 28 53.8
First 2-4 hours 17 16.3 - -
Satisfaction with the newborn’s sex
2.097b 0.148
Yes 74 71.2 31 59.6
No 30 28.8 21 40.4
c
Source of support for newborn care
4.210b 0.040*
Spouse/Partner 52 40.0 35 53.9
Relative/Friend 78 60.0 30 46.1
aMann-Whitney U test, bChi-square test, cPercentages are based on n. *p<0.05, **p<0.001.

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Özdemir et al. Infertility and Postpartum Depression

Table 2. EPDS and MIBS scores (n=156).

Fertile group Infertile group

(n=104) (n=52)
Test value p

Scales 𝒙̅ SD 𝒙̅ SD
MIBS 3.73 2.91 1.50 1.29 -5.367a 0.001*
EPDS 13.45 6.31 12.01 3.39 -1.754a 0.080
*MIBS, Mother-to-Infant Bonding Scale; EPDS, Edinburgh Postnatal Depression Scale. aMann-Whitney U test. *p<0.001.

Table 3. Correlation between MIBS and EPDS scores.

Fertile group Infertile group
(n=104) (n=52)
MIBS EPDS MIBS EPDS
Scales ra p ra p ra p ra p
MIBS 1 0.354 0.001* 1 0.082 0.563
EPDS 0.354 0.001* 1 0.082 0.563 1
a Spearman
MIBS: Mother-to-Infant Bonding Scale; EPDS: Edinburgh Postnatal Depression Scale. correlation. *p< 0.001.

Quality mother-infant bonding is a prerequisite for warranted to determine the relationship between PPD and
healthy relationships in the future (Barker et al., 2017). MIB in women receiving infertility treatment.
According to Bowlby’s attachment theory (1982),
attachment during infancy shapes an individual's life and Limitations of study
affects their relationships in the future. Women with a This study had two limitations. First, it was conducted
history of infertility have difficulty transitioning to the only in one center, and therefore, the results cannot be
maternal role during pregnancy. Women who conceive generalized to the general population. Second, the sample
after infertility treatment may have special needs because consisted only of women who underwent a C-section
they generally have concerns about motherhood and MIB because 97% of pregnant women receiving ART at the
(Bernstein et al., 1994). Women who become mothers center undergo a C-section. We thought that the delivery
after infertility treatment expresses ambivalent emotions type could affect the results, and therefore, we composed
of love and hate towards their babies. They also think that the fertile group from women who underwent a C-
they have no right to complain about their babies section.
(Sliwerski et al., 2020). Donarelli et al. (2012) shows that
women with a history of infertility have lower MIB than CONCLUSION
those who conceive spontaneously. Our IG participants The IG participants had higher levels of MIB than their
also had higher MIB than their FG counterparts (p<0.05). FG counterparts. The risk for PPD was similar in both
The baby is most sensitive in the first hours after birth. groups. There was no correlation between PPD and MIB
During this period, mother-infant interaction is critical in the infertile group. Future studies should recruit larger
for secure MIB (Donarelli et al., 2012). In our study, the samples of infertile women with cultural and ethnic
IG participants may have established a more secure MIB diversity and take confounding factors into account to
because they started to breastfeed earlier and thus investigate the relationship between PPD and MIB.
interacted more with their babies than their FG
counterparts. We also think that the IG participants may Conflict of Interest
have a more secure MIB because their pregnancies were The authors declare no potential conflicts of concerning
planned, and they had wanted to have babies for a long the research, authorship and/or publication of this
time. article.
Research shows that PPD is negatively correlated with
MIB, suggesting that the higher the levels of depression, Author Contributions
the less the MIB (Forman et al., 2007; 2020; Nieto et al., Plan, Design: SK, SK, EÖ; Materials and methods:
2017). We also found a positive correlation between SK, EÖ; Data analysis and interpretation: EÖ;
EPDS and MIBS scores in the fertile group (r=0.354, Writing and corrections: SK, SK, EÖ.
p=0.001), indicating the higher the MIB in the FG
participants. It is noteworthy that there was no correlation
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