The quality of the bond between mother and baby exerts direct influence on the child's mental health. Therefore, this relationship should be warm, intimate, continuous, and affectionate, providing pleasure and comfort for both. It is an ongoing process, initiated during pregnancy, in which the fetus becomes part of everyday life of the pregnant woman more intensely, consisting of fantasies, desires, dreams, and representations of models of motherhood.
Thus, the interactions between parents and children influence the structure of affective ties developed by the child since birth. A review performed in , aimed at describing the main instruments used to analyze the relationship between mother and child, retrieved a total of ten tools. Although there is a variety of tools to study this phenomenon, there is a scarcity of models adapted to the context of Brazilian mothers and babies younger than 1 year.
The same study found only one inventory suitable for the aforementioned population, but this tool does not apply to the context of children younger than 1 year. Selecting the most appropriate tool for a particular study requires verification of its psychometric properties: validity and reliability.
The first refers to the capacity of the tool to precisely verify what is to be measured, whereas the second comprises its accuracy to measure a certain event. It is necessary to know the characteristics of the several tools and possibilities for use in the context of Brazilian mothers and babies in detail, considering the peculiarities of this population. Therefore, the aim of this article was to identify the tools used in the assessment of the bonding between the mother and baby younger than 1 year, to describe them, and to ascertain their reliability and validity.
This is an integrative review study conducted in the publications found in the following databases: PubMed U. The review was designed to answer the following research question: are the tools used to analyze the bonding between mother and child younger than 1 year accurate and reliable? The search for the studies was performed from January to April using the following descriptors: 1 motherchild relations, 2 mother-infant relationship and its expressions, 3 validity, 4 reliability, and 5 scale.
The detailed search is shown in Figure 1. A total of 67 studies reported the use of a tool to assess the bonding between mother and child inclusion criterion 1 , and therefore were analyzed for the second inclusion criterion: investigations showing results regarding the psychometric properties of the used tools.
After verification of these aspects, 47 studies did not answer the question that conducted this study. Thus, 23 articles were included in this review. Case reports, theses, dissertations, research reports, editorials, letters to the editor, short communications, and review studies were excluded. The reliability and validity of the tools found in the included studies were assessed.
Reliability is usually investigated through stability, internal consistency, and inter-rater agreement on the scores of the tool. It is measured based on the test-retest coefficient of reliability. The studies described the bond between mother and child during pregnancy and postpartum period.
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Thirteen tools were identified: seven scales, three questionnaires, two inventories, and an observation method. Of the investigated tools, nine can be used in the first year after birth, and four during pregnancy.
A questionnaire is composed by two appropriate versions to puerperal and gestational period. The data are organized into two categories: mother-child relationship during pregnancy and bond between mother and child in the postpartum period. Regarding construct validity, a study on the feelings of fathers and mothers regarding the infant showed, through factorial analysis FA , a five-factor model for this scale. The solutions resulting from this analysis did not correspond to the original MFAS subscales and were different in the two groups. These results suggest problems related to construct validity.
This scale is adapted and validated for the population of Brazilian women. However, only its abstract is available for reading and, therefore, the research was not included in this review. The study was developed with women with gestational ages of months. The author notes that the Brazilian version of MFAS showed acceptable internal consistency, but also had limitations in its semantic content, showing restrictions regarding its validity. The MAAS consists of two versions: maternal, with 19 items, and paternal, with The scale has two components: quality and duration of the bond.
The items are answered through a five-point scale. High scores indicate a positive attachment and greater parental concern for the fetus. With regard to the psychometric properties, MAAS has been validated for Portuguese women with acceptable internal consistency. Additionally, a two-factor model 14 was found. The MAMA aims to evaluate the adjustment and maternal attitudes during pregnancy. It is self-administered, consisting of 60 items divided into five aspects: body image, somatic symptoms, marital relationship, attitudes regarding sex, and attitudes related to the pregnancy and the baby.
It has two versions: prenatal and postpartum. Values closer to 1. However, in the study by Figueiredo, 19 the latter dimension showed a correlation measure that was lower than the expected minimum. The PAI measures the affectionate feelings of the mother in relation to the fetus.
It consists of 21 items that are answered based on a four-point Likert scale. Higher scores indicate greater attachment of mother to the fetus. Regarding the construct validity, the FA showed that one factor accounted for The evaluation of the mother's emotional response in relation to the baby in the postpartum period was the objective of most tools.
The PBQ was the most often used questionnaire in the reviewed studies. It is a reliable tool to identify dysfunctions in relationships with their children, according to the alpha coefficients of the German 29 , 35 and Dutch 31 versions. Regarding predictive validity, adaptation for use in Chinese women showed adequate sensitivity to identify damage in the relationship with the baby. The abovementioned results corroborate findings regarding the validation of the original tool, wherein component 1, weakened bonding, showed to be sensitive to identify mothers with mild dysfunction in the mother-child relationship; and subscale 2, rejection and pathological rage, showed high sensitivity to identify women with severe problems related to rejection of the baby.
The remaining components of the PBQ did not demonstrate high sensitivity. Other authors have used the original version and found similar results, given that the components 1 and 2 were respectively sensitive to identify mothers with some kind of disorder in the mother-child bonding and to identify women that show rejection of the baby.
The other factors of the PBQ did not show enough predictive validity to verify additional problems in the mother-child relationship. The PBQ can be an important tool for the primary care professional, as one of its features is its use in community healthcare facilities. Some authors suggest that it is essential to train these professionals to work with the mental health of women during pregnancy and the postpartum period, to promote quality of life for parents and their children. The MIBS can be used in the first weeks after the child's birth up to 4 months postpartum to identify difficulties experienced by the mother in establishing a relationship with the baby.
It consists of eight adjectives divided into three aspects: positive, negative, and confused attachment. Negative adjectives have inverted scoring. High scores indicate problems in the mother-infant bonding. Regarding criterion validity, the aforementioned scale had high sensitivity to detect mothers with bonding alterations in relation to their children 37 and moderate concurrent validity with PBQ 34 and MPAS.
The attachment disorders detected by the MIBS are related to the fact that, in the postpartum period, women have more mood swings, which may compromise the establishment of bonding with the child. Depression is a predictor of emotional problems in the relationship between mother and baby. The PAQ is a questionnaire consisting of 19 items organized into three subscales: quality of the attachment QA , absence of hostility AH , and pleasure in interaction PI.
This tool is designed to assess the mother's emotional response in relation to the baby, especially in the first year of life. All publications that used this tool showed acceptable levels of reliability.
Mother-child bonding assessment tools
However, the Dutch version, when used for mothers of infants aged weeks, showed problems regarding reliability. The use of this version is appropriate for babies aged between 4 and 5 months. Regarding construct validity, a six-factor model in the Italian version was found.
The MAI is used to measure the attachment between mother and child. It consists of 26 items, organized into a four-point Likert scale. Higher scores indicate greater attachment between mother and baby.
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Other tools were less frequently mentioned in studies on the relationship between mother and baby in the postpartum period. The subscale of attitudes related to pregnancy and the fetus, and somatic symptoms MAMA showed problems related to the verification of the same construct in other dimensions of this questionnaire. The PAI showed criterion and construct validity, in addition to a high reliability index. In contrast, the MFAS showed limitations regarding construct validity.
The translation and adaptation for the Brazilian population of mothers and babies has been performed, but this study is not available for electronic access. As for the postpartum period, the MAI showed better reliability coefficients, but its Brazilian version has not been validated for mothers of children younger than one year. The PBQ was sensitive to identify mothers with mild dysfunction regarding the attachment with their children and women with severe problems related to rejection of their baby.
Finally, it was observed that most tools show high precision when measuring maternal-infant attachment, but some have limitations regarding their validity.
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Moreover, the majority have not been translated and adapted for the Brazilian population. Thus, it is necessary to adapt and validate these tools, considering the specific characteristics of Brazilian mothers and babies in the first year of life. Selecionaram-se 23 pesquisas, que foram lidas em sua integralidade. O detalhamento da busca encontra-se na figura 1. O estudo foi desenvolvido com mulheres com idade gestacional de 6 a 9 meses.