Maternal–fetal attachment or bonding is a natural phenomenon that develops gradually throughout pregnancy and peaks in the few weeks after the birth of the child. It is regarded as an essential process in the development of good and loving motherly behavior1. In about 8% of women this process is sub-optimal, with potentially damaging effects on the mother–infant relationship and on the emotional development of the child2. Factors associated with abnormally low attachment are depression, lack of social support and a domineering partner3. Prior to the introduction of real-time ultrasound, antenatal bonding was literally kick-started by the onset of fetal movements4 and intensified during the third trimester as the mother responded to the distinct patterns of rest and activity transmitted to her by her unborn baby1. It is now widely accepted that the early routine scans at 12 and 20 weeks are the main factors involved in initiating this bonding process5-7, although, disappointingly, ultrasound has not been shown to intensify this process in the third trimester8. Furthermore, it has not yet been demonstrated that ultrasound can make a positive impact on pregnant women with sub-optimal prenatal attachment. In this issue of the Journal, Sedgmen et al.9 describe a well-designed trial aimed at determining whether three-dimensional (3D) ultrasound enhances maternal–fetal bonding. However, they missed the opportunity to investigate the effect of 3D in the third trimester, when surely 3D, with its lifelike images of the fetus, would be most likely to make an impact. Indeed, many women regard the 3D image of the fetus in the first and early second trimesters as having an alien appearance. I would be surprised if any mother would warm to the 3D fetal image in Figure 1 of Sedgmen et al.9 and I suspect she would probably hope that it did not ‘look like me or my partner’. I would also hazard a guess that in both Figures 1 and 2 of Sedgmen et al.9, the 2D image would be more pleasing to the parents. The other missed opportunity was not to assess the impact of moving 3D, i.e. 4D imaging. As far as I am aware, no randomized study has assessed the bonding effect of 4D ultrasound in the third trimester and it is in this area that 4D ultrasound may have a unique and important role to play. In a previous Editorial I described the extraordinary response from both parents to the wide range of observable fetal activities in the third trimester10. It is the visible humanity of the fetus at this stage, the baby-like facial expressions, and the sucking, grasping and other movements that I believe could trigger a surge in bonding in the last 16 weeks of pregnancy. Even short sequences like the one illustrated here in Figure 1, would, I believe, be sufficient especially if the parents were given a video to take home so that the bonding experience could be reinforced. This would allay the fears of some sonographers that prolonging the diagnostic scan to provide a bonding experience would be impractical and difficult to justify on the basis of the ALARA principle. 4D images of a 29-week fetus taken over a 2-min period showing facial expressions and hand movements. Obstetricians rarely mention bonding when talking about the benefits of prenatal scanning. I suspect that practical, pragmatic diagnosticians feel slightly embarrassed about discussing a ‘touchy-feely’ subject such as bonding, which involves a mother's fantasies, dreams, imagination and conceptualization, and is assessed by questionnaires such as the MAAS, MFAS and PAI scales, which assess fantasy, affection, interaction, intensity of pre-occupation with the fetus and the amount of time the woman spends talking to, dreaming about or palpating the fetus. I think obstetricians would take the subject of bonding much more seriously if the impact of the ultrasound scan was translated into something of more tangible benefit, such as a change in health behavior likely to have a positive impact on the wellbeing of the unborn child. An interesting aspect of Sedgmen et al.'s study9 was their finding that there was a significant reduction in the average number of alcoholic drinks consumed by the mother after the scan. Also interesting was the finding of an inverse relationship between the number of drinks consumed and the degree of attachment on the MAAS global scale. None of the women appeared to be heavy drinkers and the numbers are small, but these findings raise the possibility that the ultrasound scan might be of benefit to high-risk women. Future studies should be randomized, should involve an assessment of 4D ultrasound in the third trimester, should assess whether giving parents a video consolidates the experience, should target the cohort of women who are sub-optimal bonders and should assess the impact of the scan on tangible health-behavior benefits.
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Mar 1, 2024
Mark A Blais + 5
Open Access