Maternal-infant bonding (MIB) is frequently discussed in research literature; however, the concept remains inconsistently defined across studies, both operationally and linguistically.1 Studies suggest that the terms “bonding,” “attachment,” and “relationship” are often used interchangeably to describe the connection between a mother and her newborn infant. The bulk of literature focused on MIB lies within the realm of the healthy, term infant. However, 8% to 12% of all infants born in industrialized countries require admission to the neonatal intensive care unit (NICU) for the management of complex and life-threatening medical issues.2 Prematurity is the primary reason for an infant to require NICU admission, which is defined as birth occurring before 37 weeks' completed gestation. The incidence of prematurity in the United States is 9.8% and 11% globally.3 Other conditions requiring NICU admission include congenital heart disease, genetic malformations, infection, and hypoxic injury. NICU admissions in the United States have increased across a 5-year trend for all birth weights, with 77.9 admissions per 1000 live births in 2012 compared with 64 per 1000 live births in 2007.4
Complex care of an infant while in the NICU interrupts MIB. Close physical contact with the newborn is critical for the maturation of MIB into a secure attachment paradigm.5 Data suggest that successful MIB in the NICU also has important implications for the neurological and stress responses of both the mother and the infant. Increased neuronal apoptosis may occur in the immature brain of the preterm infant secondary to pain and stressful stimuli; however, successful early MIB and decreased separation of the preterm infant from its mother likely relate to a decrease in the phenomenon of neuronal apoptosis.6 Epigenetic changes secondary to separation are also noted, including alteration in phenotype expression of inflammatory proteins with an inability of the infant to return to an unstressed state, altered cortical activity, impaired cognitive development, emotional programming, and long-term response to painful stimuli.5,6 A synthesis of global research shows that across 6 countries, including the United States, the prevalence of symptoms of posttraumatic stress disorder in mothers related to their NICU experience ranged from 18% to 81%, with major contributing factors being the inability of a mother to feel connected to her infant and the perception of an altered parenting role while in the NICU environment.7
The Model of Mother-Infant Bonding After Antenatal HIV Diagnosis was designed to explore and posit the relationship of variables inherent to the MIB process that occurs in this specialized situation. The authors utilized a cross-sectional qualitative study design in 10 semistructured interviews with mothers diagnosed with HIV/AIDS during pregnancy, followed by analysis using grounded theory for model creation and introduction.8 The 4 main theoretical codes identified in the model were (1) facing barriers to bonding, (2) feeling disconnected from the baby, (3) developing a special bond, and (4) strengthening and moving on. Many factors discussed in the Model of Mother-Infant Bonding After Antenatal HIV Diagnosis correlate with the experiences described by mothers facing separation from their NICU infants. Maternal-infant bonding in HIV-infected pregnant women progresses along a continuum, beginning with HIV/AIDS diagnosis and ending with infant testing and then moving on to posttesting life.8 A similar phenomenon for MIB in the NICU has been described, with the process appearing to occur progressively rather than being completely present at birth.9
The incorporation of virtual visitation (VV) into a newly developed model of NICU MIB has multiple implications for research. One area of study relates to the maternal breast milk production and somatic growth of the NICU infant. Mothers view providing breast milk for their hospitalized infant as a unique responsibility and, in doing so, an evident link of emotional closeness develops.10 Although studies designed to examine the effects of VV on maternal breast milk are lacking, anecdotal evidence shows that when utilizing VV mothers report an increased motivation to pump breast milk, a perception of potentially increased let-down reflex, and an increase in overall breast milk production.2,11 Maternal breast milk feeding is preferred over infant formula for a multitude of reasons, including a 50% reduction in the rate of necrotizing enterocolitis in the preterm infant and a shortened length of hospitalization.12 An initial hypothesis utilizing the presented model would postulate that infants of mothers who participate in VV have increased somatic growth compared with infants whose mothers do not participate. A secondary hypothesis would postulate that improved infant growth is due to changes in breast milk composition, including increased calorie and fat content, for breast milk that is pumped by mothers who actively participate in VV when compared with mothers who pump breast milk without participation in VV. Additional research areas utilizing the presented conceptual model are also possible and include evaluation of maternal symptoms of depression and posttraumatic stress disorder, the perception of separation from the infant, and the effects of VV on the occurrence of physical visitation in the bonding process.
The origin of maternal attachment theory resides with the work of John Bowlby and Mary Ainsworth. The collaboration between Bowlby's theoretical work and Ainsworth's observational studies resulted in the publication of the attachment trilogy.13 The attachment trilogy includes works titled Attachment (1969), Separation (1973), and Loss (1980). The work of Bowlby and Ainsworth revolutionized the description of mother-child attachment with recognition of bonding related to behavioral factors such as sucking, crying, and clinging to prevent maternal separation. These behaviors ultimately ensure the survival of the newborn, and mothers who are engaged in this process mature to develop a secure sense of attachment to their infant.6 The attachment factors described by Bowlby and Ainsworth influence most conventional models of MIB, including the Model of Mother-Infant Bonding After Antenatal HIV Diagnosis, and are critical to developing a new model of MIB in the NICU.8
While MIB is recognizable through maternal behaviors and self-reporting of emotions, it is inconsistently defined across published literature.1 Four critical attributes of MIB have been identified: (1) a relationship that fosters feelings of love and duty, (2) an emotional response, (3) a process that occurs during a sensitive period after birth, and (4) a unique experience tying the mother to her infant.14 The process of maternal bonding variably begins between the second and third trimesters of pregnancy and extends into the postbirth period.15 Preterm birth breaks the connection of the mother to her infant at a critical time during the prenatal bonding process. Many congenital anomalies are also discovered on prenatal ultrasound scan during the second trimester. The anticipation of an infant with a congenital malformation, likely requiring NICU admission, may also disrupt the bonding process. Regardless of the cause, mothers experience both emotional crisis and grief with the NICU admission of their newborn, contributing to interrupted bonding.
Technological advances over the last decade have made the use of Web cameras in the NICU a viable means of connecting a hospitalized infant to their parents and other family members. Known as “virtual visitation,” this method involves the attachment of a Web camera to the infant's bedside. The parents are then able to view a one-way live feed of the infant via a Web-based application downloaded to either a smart device or a computer in a secure, password-protected environment. In most instances, the camera is moved out of view of the parents only when the infant is undergoing a procedure, emergent or otherwise, such as echocardiogram or intubation. The use of VV for hospitalized infants was first reported in 1983 with the use of a videophone by mothers whose infants required transfer to an NICU in another location.16 More recently, webcam technology has been recognized as a unique opportunity to allow infants and their families to connect in real time.17 While the impact of VV on MIB has yet to be extensively studied, it is reported that mothers have an increased sense of proximity to their infant and feel “closer” to the infant when utilizing VV, suggesting a positive influence on the bonding process.2
As a novel description, the Model of NICU Maternal-Infant Bonding Incorporating Virtual Visitation introduces VV as a tool to promote bonding in the specialized circumstance of the infant requiring hospitalization in the NICU. This newly proposed conceptual model also considers the progressive nature of MIB that is likely to occur in the NICU. As the concept of VV in the NICU remains poorly defined, and its impact on the bonding process unknown, a program of research that subscribes to the presented model of MIB will address knowledge gaps regarding the true effects of VV for both the mother and the infant.
The purpose of a program of research utilizing the foundational model presented is to examine the effect of VV on the provision of maternal breast milk for the NICU infant with the subsequent outcome of improved growth. We hypothesize that mothers who move through the bonding process successfully, using VV as a bonding enhancement tool, will have an increased motivation to pump breast milk for their hospitalized infant. Subsequently, the infant will display improved somatic growth when compared with infants fed breast milk that is pumped by mothers not utilizing VV. Our secondary focus is to examine why infant growth is improved in this scenario. We hypothesize that the breast milk of mothers participating in VV will contain increased nutrient density upon analysis, including fat and calorie content, resulting in improved infant somatic growth.
Other research goals utilizing the presented model are to examine the long-term health benefits that stem from the impact of VV on the NICU mother and infant, utilizing qualitative and quantitative research designs. We aim to conduct qualitative research to evaluate the influence of VV on symptoms of maternal depression and posttraumatic stress disorder. Quantitative research will be conducted to investigate changes in the overall length of hospital stay and readmission to hospitalization rates for infants whose parents participate in VV as compared with parents who do not. Using the relationships presented in this model, we have created a foundational research program guiding efforts to better understand NICU MIB and its effects on the mother and her infant.
The Model of NICU Maternal-Infant Bonding Incorporating Virtual Visitation is presented in Figure 1. The themes of the model are plotted chronologically from the points of threatened birth of an infant known to require NICU admission to the eventual discharge of the infant to a home environment or death. The model recognizes that barriers to MIB likely begin at the point a mother discovers that her newborn will require critical care, such as in the case of prenatally diagnosed complex congenital heart disease. However, the birth of an infant requiring NICU admission is often an unanticipated event, and this scenario is also represented in the model. The leading causes of infant mortality in the United States are birth defects and prematurity, and both populations will require NICU care.18 While mothers who experience the death of an infant may follow a different postdeath grief trajectory, they have faced similar barriers to bonding as mothers whose neonates viably reach NICU discharge. Therefore, both discharge and death are represented as infant outcomes in the model timeline.
The arrows in the model represent how one concept influences another. The solid, one-sided arrows represent a one-way, causal direct relationship between conceptual propositions. The solid, double-sided arrows represent bidirectional and mutually influential relationships between concepts. The dotted arrows represent an interactive and bidirectional relationship between multiple conceptual propositions and demonstrate how a mother may fluctuate back and forth between concepts as she progresses along the bonding continuum. Virtual visitation is introduced to represent a moderated causal variable. The relationship between impeded bonding and feelings of disengagement changes as a function of VV. Likewise, VV continues its influence as the mother progresses into the formation of a special bond with her infant. Strengthening to move on is the final proposition represented in the model, with VV continuing to affect the process of MIB to the point of NICU discharge or death of the infant.
Each conceptual model proposition contains related themes that provide evidence and rationale for each of the 5 propositions described. While not directly represented in the Figure, these related themes are important for the understanding of the model function and propositional relationships.
Feelings of guilt, anxiety, and depression
The overarching feeling experienced by mothers during the hospitalization of their infant is that of guilt secondary to the internal perception that their body “failed” in gestating a healthy infant and the perceived suffering experienced by the infant.15 NICU mothers are known to have an increased prevalence of depression associated with the hospitalization of, and early separation from, their infant.5 Significant depressive symptoms are seen in 38% of NICU mothers, with symptoms often already present in mothers who anticipate the NICU admission of their preterm infant.19
Grief due to alteration in motherhood expectations
Mothers of NICU infants experience a period of mourning the loss of a healthy infant and must adjust their parenting expectations. Mothers also report feelings of emotional shock, disbelief, emptiness, and loss of control after delivery of the preterm infant requiring NICU admission.15
Fear of NICU environment and infant outcome(s)
The unfamiliar environment of the NICU may result in maternal feelings of alienation and distraction.20 Mothers may also feel threatened by the overwhelming use of complex technology used to support their infant, including machines with multiple alarms, as well as the tightly controlled NICU routines.15 The Isolette that houses the infant may be seen as a physical barrier, serving to increase the perception of maternal separation from her infant.6 Fear of losing their child, and uncertainty about the infant's future, are also present, especially during the first maternal visits to the NICU.15
Feelings of disengagement
Feelings of maternal inadequacy
Early maternal separation from her infant leads to immense stress, feelings of incompetence, and alienation from the infant that may lead to physical and emotional withdrawal.5 Feelings of maternal inadequacy are also likely compounded by the absence of early breastfeeding opportunities and the perceived inability of the mother to protect her vulnerable infant.10,15 Mothers also report feeling as if they have abandoned their infant when they leave the NICU to manage other life responsibilities, including the care of other children.20
Inability to perform routine parenting activities
The ability of a mother to perform the usual tasks of motherhood, such as feeding, cuddling, and diapering, her newborn infant is severely restricted in the NICU due to the critically ill nature and the inability of infants to tolerate physical touch or manipulation. Many women report not feeling like a mother and not recognizing the infant as their own during their initial days in the NICU, with compounded feelings of exclusion because they are unable to make decisions for, or participate fully in, the care of their hospitalized infant.15
Disconnection as a protective mechanism
Fear of death and uncertainty regarding the infant's medical outcome halted MIB in mothers antenatally diagnosed with HIV/AIDS.8 A similar phenomenon exists for mothers of NICU infants. The fear of infant loss is increased in early visits to the NICU and may result in the mother avoiding both seeing and touching the infant.15 Neurologic dysfunction and immaturity in the sick or preterm infant also make it difficult for mothers to receive reassuring feedback from the infant.9 Therefore, our model asserts that the lack of infant feedback may contribute to the disconnection of the mother from the infant during the bonding process.
The relationship between the concepts of impeded bonding and feelings of disengagement in the proposed model indicates that these concepts are both bidirectional and mutually influential. We hypothesize that impeded bonding increases maternal feelings of disengagement from her NICU infant. Likewise, feelings of disengagement serve to impede the MIB process. The introduction of VV shortly after the admission of the infant to the NICU moderates these variables to promote the forward movement of the mother along the bonding continuum.
Formation of a special bond
Physical closeness and connection
A significant increase in the sense of connection with the infant was reported by mothers when expressing breast milk for their hospitalized infant, and the maternal perception of reciprocity was received from repeated infant interactions such as eye contact and the infant squeezing the fingers of the mother.21 Mothers report an increased sense of proximity to their infant, and they also feel “closer” to the infant when utilizing VV.2
Participation in activities and kangaroo care
Although often limited in the NICU environment, mothers reportedly feel a strong sense of pride in simple caretaking tasks.10 Changing diapers, feeding, holding, interacting, and getting the infant to sleep increased MIB by allowing mothers to feel as if the infant was their own.20,21 The initial episodes of kangaroo care, or placing the infant skin to skin, are reported as the first time parents may have felt as if the infant was theirs.5 Virtual visitation allows mothers to view hands-on daily care activities provided to their infant by the bedside NICU staff. Subsequently, mothers gain secondhand experiences in these activities and develop confidence in the participation of these care activities, including touching, holding, and kangaroo care, as the MIB process progresses.
Becoming part of the medical team
NICUs, whether configured as a private room or open-bay design, typically invite parents to actively participate in the infant's care as part of the medical team. Mothers reported increased feelings of connection to the infant when treated as part of the medical care team, including the transparent sharing and availability of information, inclusion in decision making, and ability to participate in daily, multidisciplinary rounds.20
Positive staff relationships
Positive maternal relationships with NICU staff members contribute to MIB by promoting maternal well-being, trust that the infant is safe and adequately cared for, and connection to the infant.21 Nurses are in a pivotal position to promote MIB through repeated contact and involvement of the mother in the daily care of the infant.15 Virtual visitation allows mothers to remotely view much of the nursing care that is provided to their hospitalized infant, further fostering the development of positive staff relationships.
A solid, single-sided arrow is used to display the relationship between the proposed model concepts of feelings of disengagement and formation of a special bond. We contend that an NICU mother who engages in VV as a bonding tool will progress past feelings of disengagement and successfully form an exclusive bond with her infant. While the mother may continue to have insecurities regarding independently providing daily care to her infant, we anticipate that once a mother has progressed forward in the bonding trajectory to form a special bond successfully, she will not regress to feelings of disengagement and/or impeded bonding.
Strengthening to move on
Feelings of autonomy, comfort, and competence
As MIB progresses, mothers begin to develop competence in the NICU environment and are subsequently empowered by opportunities to provide care autonomously for their infant.20 Maternal confidence in caring for her hospitalized infant is enhanced, and a positive relationship is facilitated when the mother has frequent contact with her infant.5 In this model of MIB, we propose that as the mother's bonding matures, she will gain comfort in her ability to provide care for her hospitalized infant. Virtual visitation will also further improve the maternal perception of comfort with her hospitalized infant.
Looking forward to the future
As the maternal-infant bond solidifies, a mother begins to envision a future with her infant. Signs of medical improvement, such medication weaning, moving from an incubator into an open crib, removal of tubes and machines, and the visible weight gain of the infant, provide positive signs of present and future infant well-being.10,21 These signs of medical improvement occur as the infant progresses toward discharge from the NICU. Mothers discover a new sense of responsibility related to the discharge of their infant from the NICU, and apprehension mixed with feelings of joy is prevalent as the mother prepares to care for her infant at home without the support of the neonatal team.22 Even mothers planning to take home a medically complex infant, often with ongoing medical needs, report feeling both optimistic and fortunate at the time of NICU discharge.22
As mothers look forward to the future with their infant, they may also begin to find personalized meaning within their individual NICU experiences. “Faith in a higher being” allowed many women diagnosed antenatally with HIV/AIDS to find meaning and purpose in the experiences of themselves and their infants.8 Likewise, NICU mothers begin to look more intently at the “big picture” with positivity in their experiences and anticipation of the future with their infant.22
The concept of strengthening to move on is related to the formation of a special bond in a mutually influential and bidirectional fashion. The formation of a special maternal bond with her infant fosters the forward progression of a mother along the bonding trajectory toward anticipation for the infant's future. Likewise, we theorize that finding the strength to move on, and developing a vision for the future with the infant, promotes continued maternal-infant bond formation.
Virtual visitation as a bonding enhancement tool
The impact of VV on the maternal-infant bond in the NICU is yet to be well defined or extensively studied. However, the proposed model presents VV as a moderated variable in the trajectory of MIB. Despite the brevity of published literature regarding the direct impact of VV on MIB, there is reason to believe that it has a positive impact on the bonding process. For example, unrestricted access to the infant favors the MIB process.15 Virtual visitation provides this access in an easily accessible fashion. Mothers also report increased feelings of closeness when pumping breast milk near their infant.20 For the mother who cannot be physically present to pump breast milk at her infant's bedside, viewing the infant via VV may provide an adequate substitute. Virtual visitation enhances the feelings of connectivity and closeness for parents who had few means to be physically present with their infant.5 Parents also reported reduced stress and enhanced satisfaction with 24/7 remote access to their hospitalized infant.17,23 The phenomenon described launches an evidentiary foundation that VV may successfully enhance MIB.
Despite early barriers to bonding, most mothers with a prenatal diagnosis of HIV/AIDS were able to develop a strong maternal-infant bond.8 As NICU mothers also face the process of bonding in difficult circumstances, it is postulated by the Model of NICU Maternal-Infant Bonding Incorporating Virtual Visitation that these mothers will also achieve a strong maternal-infant bond. The proposed model accounts for the specialized circumstances and barriers to bonding encountered by the mother with a hospitalized infant and utilizes the emerging technology of VV as a vital tool in promoting the MIB process. Utilizing the Model of NICU Maternal-Infant Bonding Incorporating Virtual Visitation, along with the continued critical evaluation of all related factors, will promote further research development in the arena of the NICU.
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