Here is a project written for the massage and pregnancy diploma course by Claire Wynn
Role of massage in supporting mother-baby bonding.
This essay discusses the importance of the mother baby connection during pregnancy, how this could influence the future wellbeing for the baby and the family later in life and the role of the massage therapist in supporting this.
There is a general wisdom that better mother-baby bonding is thought to improve a child’s wellbeing later in life. That children who have developed positive and secure bonds with their care giver are more likely to evolve into happier, more intelligent and successful adults. Children who have not had secure bonding experience as a contrast are more likely to develop problems with anger, lower intelligence, antisocial behaviours and mental health issues. Therefore any intervention or activity that is likely to improve this bond could be beneficial for a child and their family.
I first want to clarify what I mean by mother-baby bonding. The words “bonding”, “connecting” and “attachment” are words that have been used interchangeably throughout literature and without proper defining can create confusion with the reader as, in certain instances, they have very specific meanings which are different from each other.
According to Benoit (2004) ‘Bonding’ was a term originally coined by Klaus and Kennell (1976) to mean the parent child bonding that was dependant on skin to skin contact during an early critical period just after the infant was born. It is closely related to contact such as breast feeding and has been used as a rationale for encouraging this. However, research has shown that skin to skin bonding has actually been found to be a poor predictor of children’s outcomes.
The Concise Oxford English Dictionary defines ‘bonding’ as
”1 join or be joined securely to something else….2 establish a relationship based on shared feelings or experiences”
So here we begin to view mother-child bonding as less about the reliance on skin to skin contact and more about the development of loving feeling between the two people, based on how they interact together.
Benoit (2004) describes attachment as different to bonding. It is about the parent or care giver playing an important role in the child’s early development to support secure attachments. Good attachments are formed by the parent or care givers actions which ensure the child feels safe, secure and protected. This concept is based on Attachment Theory (first developed by Bowlby in 1969) and there is generally felt to be four types of attachment; ‘secure’ ‘avoidant’ ‘resistant’ and ‘disorganised’ depending on the care givers style of parenting. In this instance research has shown that the type of attachment that a parent-child develops, has important outcomes for the child’s wellbeing later in life.
The Concise Oxford Dictionary defines attachment (in relation to people) as
“Affection or fondness”
Here it is more about the feelings that are developed for another person.
The term ‘connection’ has been used less in research, but has been used in literature when discussing the feelings or relationship between a parent and a child. The Concise Oxford Dictionary defines the term as
“A link or relationship between people or things.”
In this essay I will use all three terms interchangeably and my meaning by using these terms includes aspects of all three definitions. I am not referring to skin to skin contact at a critical stage after birth but the development of a close interpersonal relationship of deep affection and love that develops between the mother and child, and the security and safety that the child feels from this. I will later on specifically refer to the period during pregnancy where a mother may begin her emotional connection to the growing child within her.
I will discuss how it is possible that the more secure and connected that the mother feels with her baby when it is in the womb then the more positive the attachment can become, postpartum. The development of this connection during the pregnancy period can influence the wellbeing of the child and their families later on in life.
Why is bonding and attachment important?
Most of us believe that a positive mother-baby bond is likely to be beneficial to a child and their family and there is plenty of research that has explored the link between secure attachments and childrens wellbeing.
Attachment theory was first developed by Bowlby (1969). He concluded from his research that all children are born with an innate need to form secure attachments to their care giver which then will influence their survival. Maternal deprivation or the lack of opportunity to form these bonds led to outcomes such as depression, aggression, lack of empathy and lower intelligence later in life. In contrast, the development of secure attachments were good predictors of better childrens wellbeing.
For example Hoeve et al (2012) found that poor attachment to parents was significantly linked to delinquency and Lee and Hankin (2009) have discussed the role of poor attachment in influencing depression in adolescence. There are many more studies showing links between poor attachment and other negative child outcomes.
As a pregnancy massage therapist the idea that supporting a parents bonding to their child can have a positive influence later in life is very appealing and one that the massage therapist could actively support during treatment sessions, especially if they continue to support the mother after the birth. This concept is even more appealing if there is a direct link between mother-child bonding whilst the child is still in utero. In this instance the pregnancy massage therapist could then potentially have a much more direct and active role in supporting this wonderful relationship between the mother and her unborn child.
Fortunately there is plenty of research showing the importance of influences to the unborn child in utero. Decasper and Spence (1986) found that babies can recognise and preferred their mother voice just after they are born and Partanen et al (2013) found that babies recognised lullaby’s played to them whilst in the womb after they were born for several months. The idea that a child can recognises ones voice, a song could support the relationship, the connection to the unborn child as their early senses and cognitive responses are being developed this early.
Siddiqui and Hagglehoff (2000) found that prenatal attachment is a good predictor of post natal maternal involvement with their baby, i.e. a mother who develops strong bonds whilst pregnant is much more likely to bond well with that child after the birth.
In contrast to this, the Wave report, identifies certain behaviours during pregnancy that are poor predictors of positive child outcomes later on, such as domestic violence, depression/stress and drug misuse/alcohol. All behaviours can may well have a negative impact on the mother’s ability to bond with her baby whilst pregnant.
Luminare-Rosen in her book ‘Parenting begins before conception’ (2000) would argue that connecting with your child can begin even before conception. She writes about the importance of careful prenatal considerations that can shape a child’s physical, emotional, mental and spiritual wellbeing. She writes
“ …we have learned that a baby in the womb has developed the emotional and intuitive sensitivity to experience the mothers inner and outer life. He hears his mother’s voice and senses her love…A child who experiences prenatal bonding is often more alert and enters the world with an innate sense that she is loved and wanted.”Luminare-Rosen, 2000, p212.
Factors that can interfere with the bonding process during pregnancy.
If only things were that simple! Life however is rather complex, and there are many factors that influence a mothers experience and of being pregnant. Factors that can certainly make the process of conscious bonding with her unborn child much more difficult. When working with pregnant women during massage sessions, and talking to other women who have already been mums, those that have lost, and those who have still to be, I have discovered a myriad of factors that can influence her connection to her baby in womb.
Fear of loss/High risk pregnancy
During the first trimester of any pregnancy miscarriage is a possibility. According to the miscarriage association (www.miscarriageassociation.org.uk), 1 in 4 pregnancies end in miscarriage. The risk of miscarriage usually reduces as one enters into the second trimester however some women will still miscarry later in their pregnancy than this, especially if this has happened before or of the woman is in a particularly high risk group (presence of pathology) that means they are more likely to miscarry.
The impact of the possibility of loss on a pregnant women, can interfere with the process of bonding with her unborn child. This is a normal emotional protection for the mother, and for women who have experienced multiple miscarriages or later pregnancy miscarriages, may prove to be an even stronger factor for them. One woman I spoke to who had experienced previous miscarriages told me:
“ the main difficulties were worries about miscarrying for both of us which meant that we were kind of denying it was happening…..we didn’t even put up the cot or buy nappies until after Billy was born” (names changed to protect confidentiality)
Another one of my clients felt she had no real reason to suspect a miscarriage but this was on her mind throughout the pregnancy:
“I’ve been much more concerned about losing the baby this time, unnecessarily and I don’t know why! William was named by 20 weeks but this time, I still refer to the bump as baby….I hope when she arrives, I will feel more of a bond than I do right now..” (names changed to protect confidentiality)
There is an extensive amount of literature about post natal depression and the effect of this on the child parent attachment. It is a recognised complication and risk in the post natal period. Midwives, health visitors and GP’s have an understanding of this condition and are trained to look out for this possibility in new mums.
However it is now more widely recognised that some women can experience depression during their pregnancy, especially in the first trimester and for some women further or even throughout the whole pregnancy. Symptoms can include:-
- Chronic anxiety
- Incessant crying
- Lack of energy
- Relationship worries: worrying their partner may leave once the baby is born
- Conflict with parents: pregnancy can often stir up emotions regarding their own up bringing
- Fear of seeking help
PANDAS (Pre and postnatal depression advice and support) wwwpandasfoundation.org.uk is a really useful website for support and advice on prenatal and postnatal depression.
Two women spoke to me about their experiences:
“ I was ridiculously hormonal and quite tearful…all fine now and we’ve both definitely bonded”
“ I felt so low I wondered what on earth I thought I was doing getting pregnant…I felt odd and surreal at times…I even contemplated having a termination”
For the majority of women life goes on. Just because one is pregnant it does not mean that the responsibilities of regular life are suddenly put on hold. Women still continue to work, look after their children, socialise with friends, move house and deal with stresses and strains that life can bring. Life can be so busy, and we often do not have time to put aside to really pay attention to the miracle that is growing inside the body.
For first time mothers, this can be easier (although not always) and can be exciting learning about ones changing body and the growing baby inside the womb. However if a mother already has a toddler or baby to consider finding time to really enjoy this process is a luxury that can often be put aside whilst she deals with juggling work, mealtimes, nappy changing, playing with her children etc etc.
The second time mothers in my case studies seemed less connected to what was happening during their pregnancies. Conversation was about feeling tired, not having time to stop. They often rushed in and would speak about their aches and pains, and seemed to have to really think, when I asked them about their baby or how they felt about their pregnancy.
Financial demands can have a big impact for families. These days, both parents are often working full time in order to manage the increasing demands of the cost of living. Choosing when to stop work whilst pregnant is a timely affair. Stopping too soon can have a knock on affect to having to return to work earlier after the birth, leaving it late can mean some women end up working very close to their due dates. But finishing work, releases precious time to muse and prepare for arrival of the baby.
“stopping work has helped as I have had more ‘me’ time to contemplate what’s ahead”
During pregnancy, the body is undergoing massive changes to accommodate the growing child within. For many women, pregnancy is a time when they are ‘blooming’ and women can enjoy this time enormously but for a lot of women, pregnancy is not a comfortable process at all, and for most there are certain anatomical impacts on the body that make the pregnancy a challenge to manage.
Issues that are often present during the first trimester are sickness, tiredness, headaches, sensitivity to food, heavy breasts to name a few of the challenges. In the second trimester, the time when most women are said to be ‘blooming’ these issues can continue, in addition other issues such as changing shape and body image perceptions, increasing weight, cramps, indigestion all can take their toll. The third trimester is the time of the major structural changes where postural imbalances can take a major toll on the body creating muscular and ligament issues. Other problems such as varicose veins, constipation along with pregnancy related complications such as gestational diabetes, preeclampsia, and placental issues are more likely to develop.
Physical discomforts can certainly interfere with a mothers focus on bonding with her baby, certainly if she is experiencing more serious problems that may require medical intervention.
Fortunately all of my case studies had fairly smooth pregnancies with minimal physical health factors that impacted on their lives.
A good friend who did experience extreme vomiting during her pregnancy told me how isolating and helpless it made them feel.
Substance misuse can lead to impaired childhood development and low birth weight and can interfere with a mother ability to act in the interest of her child’s health and safety. Studies have found that substance misusers are more likely to have impaired attachment, experience guilt, uncertainty and concern through their pregnancies. Alhusen (2008)
Given the potential strains and challenges on a women’s physical and emotional wellbeing, pregnancy can throw up a lot of challenges for her. Women who have a good support system are likely to feel more supported and comforted during pregnancy. Studies have shown that women who have better support such as good relationship with the father to be and high levels of closeness and intimacy in family relationships tends to have higher levels of maternal bonding. Alhusen (2008)
Supporting the connection with the unborn child?
So faced with the challenges that may interfere with the bonding process, what can a mother do to support her connection with the growing baby during her pregnancy? Here are some ideas.
- Have a bath. There are many benefits to having a bath when pregnant. The water helps lift the weight off the ever increasing bump and can help soothe aches and pains that this brings. In addition, relaxing in the bath can provide vital time-out and a quiet opportunity to be with the baby.
- Get support. For those who don’t have close family or a partner, finding local groups where other pregnant women attend can provide an opportunity to meet and share challenges with other women. Groups can be found by looking in local children centre notices, National Childbirth Trust (NCT) website, local papers, websites such as netmums.com. Or local health centre noticeboards.
- Eat healthily and appropriate exercise. Choosing a healthy lifestyle not only provides the baby the best start, but can ensure the mother is in optimum health which may help to prevent some physical issues developing. In turn a more comfortable pregnancy is likely to improve opportunities for bonding with the baby. Having a positive attitude to your and your babies health is a form of positive connection with your baby.
- Talk/sing to baby. The partner can be included in this too!
- Pregnancy yoga. This is becoming more popular and can be extremely supportive of a pregnant women’s, physical, emotional, spiritual and social wellbeing.
- Visualisation/Meditation. There are good visualisations that can be found on the internet or in pregnancy books and CD’s. These can help a mother relax. Some are specifically designed to promote parent-child bonding.
- Support for depression. Depression can lead to feelings of guilt, shame and helplessness. Feelings which can interfere with the ability to seek support. However, there is a lot of support available for women with depression, a good start is looking on pandasfoundation.org.uk which is a website offering advice and support for prenatal and postnatal depression. Talking about how one is feeling can be fundamental to managing depression. GP’s, midwives should be able to offer support or refer to specialist services if required.
- Pregnancy massage. More details about how massage can help will now be discussed.
How can massage help?
I firmly believe that massage during pregnancy can have great value for the mother and her child in supporting maternal bonding. Whilst I am unaware of any particular research that has looked at massage and maternal-foetal bonding directly. Field et al (1999) found that pregnant women had reduced anxiety, improved mood, better sleep and less back pain.
Bellini et al (2007) found that women who were offered Prenatal Education Course (PEC) positively influenced prenatal attachment, which involved basics of foetal physiology and development, singing sessions, dance sessions and massage-through-the-womb sessions. As we shall see, pregnancy massage sessions are more than hands-on bodywork and supporting physical aches and pains. Pregnancy massage sessions can include, emotional support, education, abdominal/foetal massage and involving partners. Much of some of the activity offered by the PEC courses.
A closer look at how pregnancy massage can help support bonding
A wonderful, and possibly the most direct way during a massage session to help support the connection for the mother with her baby is through the use of guided visualisation. This was a technique that I used on several occasions during my case studies.
Case study A, B and C all were busy second time mums. They did not feel they had time to stop and reflect and get to know their growing babies in their wombs. Often life was focussed on their young children or work. With their permissions I used powerful connecting visualisations during at least one of their sessions with them. Client C had the most powerful response, she was able to feel a connection and a communication during this that she had not experienced before. Her demeanour changed and I felt privileged to be part of this moment.
“I really loved the visualisation, I was able to really spend time with my baby. Normally this time of day she is quiet but today she decided to wake up…I felt that she was somehow communicating with me”
A different scenario was presented by client D. She had disclosed some difficulty with her connection to her baby, relating to a fear of a negative outcome after the birth. She had a cousin who was born with severe learning difficulties. This had impacted on her and her families lives, and the fear of this happening again was interfering with her connection to her unborn child. We had discussed the usefulness of a guided visualisation and she very much wanted to do this. She found the visualisation session helpful and enjoyed it on the most part. Some aspects of the visualisation were too intense for her, which highlighted to me what a powerful tool it can be, and one that needs to be used sensitively and wisely, tailoring and pitching it at a level which would have the best and sensitive impact to the receiver.
Energy holds on the lower back (ming men) and abdomen can be a powerful way of bringing awareness to the womb and supporting the energy flow in this area. The 3D effect, of holding both areas at the same time brings the attention inside the body and to the womb in a gentle way.
Client B’s energy and focus changed as I used holds in this area. She seemed to switch from the general chatter into a powerful state of internalisation.
Working on the abdomen has many benefits such as easing abdominal aches and pains and supporting digestion. It also can bring focus and includes the baby into the massage session. For many women, bodywork involving the abdomen is new, as women do not usually experience touch in this area from other people.
To begin with most of my case studies expressed some apprehension about me working on the abdomen during the session but all wanted this. After working sensitively and at a pace that allowed them to feel comfortable with this, all of them enjoyed this aspect of the massage and wanted this on each session. There was a general feeling that the baby was also getting a massage too.
“ I found it a bit tickly at first, but I thought the baby might like it”
“I liked the belly massaging – would have been happy with more of it”
“I liked my bump massaged, actually that felt very natural as part of the massage”
Any massage technique that can bring a reduction in symptoms of depression/anxiety is likely to also support bonding attachment. As we have already explored that depression can be a factor in reducing the maternal bond and that reducing anxiety can be a factor in supporting maternal bonding.
None of my case studies were experiencing depression however Client B certainly brought issues relating to her body image and loss of control. Client E, experienced panic attacks in the first trimester. Client C reported to me that the sessions really helped her to relax and for one session after a particularly stressful week of tests this was her main focus.
All my clients reported feeling more relaxed after every session.
Improving physical symtoms
The possible physical symptoms that a massage session may support include the flowing:
- Muscular aches
- Joint pains
- improve circulation
- reduce oedema
- reduction in headaches
- improve sleep
- sciatic nerve pain
Most of my case studies has some form of muscular or joint pain, some had sciatic pain and one had headaches. In each instance the massage sessions seemed to help with these. One client had suffered with oedema in her legs and feet in her last pregnancy, unfortunately I did not get to work with this during these sessions but the lymph drainage techniques, given an opportunity may well have been beneficial for her.
Support for high risk mothers
Some of the possible presentations of a high risk pregnancy may include
- first trimester mothers
- multiple pregnancy
- gestational diabetes
- previous history of high risk pregnancy
Given that women in a high risk group are also more at risk of physical complications, depression, stress and poor bonding then these are the very people who may benefit most from massage and it can be a useful adjunct to other medical interventions. There are many myths persisting about the possible dangers of massage in pregnancy, but any total contraindications to bodywork in pregnancy are rare. Any bodyworker who is supporting a high risk pregnant client needs to have adequate training and knowledge to work with this group. They need to be competent in liaising with the primary caregivers if appropriate, to understand specific adaptations, considerations and contra-indications and when to cease bodywork altogether and refer to a medical practitioner.
In the absence of a partner, family or friends, the massage space can give the expectant mum an opportunity to feel cared for, supported and able to talk about herself, her needs and find solutions during the session. This can be especially important during the first trimester when women are often reluctant to announce their pregnancy due to high risk of miscarriage in this stage. At this time the massage therapist may be the only other person who knows the woman is pregnant.
“It’s been really helpful to be able to talk about the pregnancy, it makes it seem more real”
Partner sessions, especially in the later stages of pregnancy can be extremely beneficial to enhance the support that a birth partner may give to the pregnant woman during labour, and can be invited in to a session and be shown various techniques which he may use with her, or encourage her to do during the labour. Increasing involvement of the partner can also support the partners bonding towards the baby, mother and family unit as a whole.
During my case studies, I had one partner session with Client E.
Although in this instance the partner was ambivalent about attending, he engaged well with the session and they had fun trying out some of the techniques. Client E told me that his attitude was very much that the pregnancy and labour was her job. The session brought to his attention that he very much had a role to play. I hope this helped him be more connected to the baby and the birth.
A space to reflect
During my case studies I had many clients who complained of feeling tired and busy with little time to focus on their pregnancy
“I still haven’t really accepted that I am about to have another baby! Better start thinking about it I guess?”
Most already had children with work commitments on top. Client C seemed to have little time to spare for her current pregnancy and really benefitted from the space to relax and reflect on her pregnancy.
“ the massage sessions sessions really helped me to take time out to relax during my pregnancy, not an easy thing to do with work commitments and 2 small children to care for”
Client B, was also a busy working mum, who was in the middle of moving house and developing her family’s business. Her feelings about her changing body but also the stress of her current hectic life changes were particularly interfering with her connection to her baby
“Claire also helped me connect with my unborn baby in my sessions by focussing on the baby and my body. This was important for me as I was so busy throughout my pregnancy I felt I had no time to stop and focus on what was happening and my baby”
Aftercare is always an important part of any massage session as it can help empower an individual to self-manage aspects of their wellbeing.
Much of the aftercare is about educating the expectant mother on different aspects of their pregnancy, giving tips and advice to do at home. Some aspects of aftercare may have a direct impact on bonding such as giving information on guided visualisations. Other aspects such as good posture, breathing, pelvic exercises etc. all have their part in supporting the mother and her baby physically and emotionally throughout the pregnancy, thus reinforcing the best possible environment for optimum health, knowledge and mother-baby connection.
The most obvious time for a mother to form a strong bond with her baby is in the period after the birth, when she meets him/her for the first time face to face. This can also be a time when massage may be extremely useful in supporting the mother and ultimately the attachment to her child. Post natal massage needs to be done sensitively and in a way that will support this bond.
Finding time to attend a massage session however can be challenging with a newborn baby. A mother can be exhausted by the new demands the baby brings and creating the opportunity to look after herself can be difficult. This can be a wonderful time to offer home visits and or offer sessions with her baby present. Massage can be successfully performed on a futon on the floor with her baby lying next to her. The baby can happily sleep in this position and/or the mother can be shown how she can comfortably breast feed her baby whilst in a side lying position, whilst she receives some massage. This can be extremely relaxing time for the mother to be with her baby and help promote their bonding to each other.
Developing positive mother-baby attachments, is an important predictor of a child and their family’s future wellbeing and can begin as early as pregnancy or even preconception. Early bonding during pregnancy has the potential to improve mother-baby attachments after the birth.
However, pregnancy can be a challenge, and issues such as physical discomfort, risk of loss, depression, lack of social supports to name some of the issues, can interfere with positive mother baby connections. Therefore, supporting a mother through her pregnancy with a focus on supporting the mother connection to her baby is likely to have a positive influence on the whole family’s future. A pregnancy massage therapist can have an important role to play in supporting a mother and ultimately the family’s connection with their new baby.
Whilst working with the amazing women I have been privileged to meet, I have felt humbled by the role I have been able to play in supporting the women during their pregnancy. It is a wonderful feeling to be able to be such a positive part of the development of a new life and the new journey for those women and their families, and I hope that they have benefitted from this experience as I surely have. I would very much like to thank all the women and their partners who have contributed to my learning journey.
References, resources and information
Bowlby, J. (1969). Attachment. Attachment and Loss: Vol. 1. Loss. New York: Basic Books.
Concise Oxford English Dictionary (2011). 12th edition. Oxford. Oxford University Press
Gordon, Y. (2002) Birth and beyond. London. Vermillion.
Klaus MH and Kennell JH(1976) Maternal-Infant Bonding: The Impact of Early Separation or Loss on Family Development. St Louis: Mosby.
Luminare-Rosen, C. (2000) Parenting Begins Before Conception. Vermont. Healing Arts Press.
Yates, S. (2010) Pregnancy and Childbirth. London. Churchill Livingston.
Alhusen, J.L. (2008) A literature update on maternal-fetal attachment. Journal of Obstetric Gyneacological and Neonate Nursing. 37:315-28
Bellieni CV, Ceccarelli D, Rossi F, Buonocore G, Maffei M, Perrone S et al.(2007) Is prenatal bonding enhanced by prenatal education courses? Minerva Ginocol 2007; 59: 125–9.
Benoit, D. (2004). Infant-parent attachment: Definition, types, antecedents, measurement and outcome. Paediatrics & Child Health. 9(8), 541–545.
Decasper, A.J. Spence, M.J (1986) Prenatal Maternal Speech Influences Newborns Perception of Speech sounds. Infant Behaviour and Development. 9, 133-150.
Field, T., Hernandez-Reif, M., Hart, S., Theakston, H., Schanberg, S., Kuhn, C. & Burman, I. (1999). Pregnant women benefit from massage therapy. Journal of Psychosomatic Obstetrics & Gynecology. 20, 31-38.
Hoeve, M., Stams, G. J. J. M., van der Put, C. E., Dubas, J. S., van der Laan, P. H., & Gerris, J. R. M. (2012). A Meta-analysis of Attachment to Parents and Delinquency. Journal of Abnormal Child Psychology. 40(5), 771–785.
Lee, A., and Hankin, B. L. (2009). Insecure Attachment, Dysfunctional Attitudes, and Low Self-Esteem Predicting Prospective Symptoms of Depression and Anxiety During Adolescence. Journal of Clinical Child and Adolescent Psychology. 38(2), 219–231.
Partanen E, Kujala T, Tervaniemi M, Huotilainen M (2013) Prenatal Music Exposure Induces Long-Term Neural Effects. PLoS ONE 8(10)
Siddiqui, A and Hagglof, B (2000) Does maternal prenatal attachment predict postnatal mother-infant interaction? Early Human Development. July; 59 (1). 13-25.
Wave Trust; Department for Education (2013) Conception to age 2 – The Age of Opportunity. TSO, London.