Securing the Foundations of Attachment Prior to Birth as Essential to Development A Triadic Perspective of Perinatal Wellbeing

We are delighted to publish this informative article written by Antonella Sansone-Southwood. 

About the author

Antonella Sansone-Southwood is a mother of two girls, doctor in Clinical Psychology, MA, Educator, Researcher, Mindfulness Teacher/Facilitator, Author of Mothers, Babies and their Body Language (Karnac, 2004), Working with Parents and Infants: A Mind-Body Integration Approach (Karnac, 2007) and several articles.

She has a special interest and research focus on the impact of the pre and perinatal period on human development and health, in particular on mother-baby pre/perinatal relationship and the influence of the father, integration of primal wisdom and science, psychosomatics, mind-body approaches to prevention and healing. Antonella’s several years clinical, educational, research work and experience with African indigenous cultures, in particular, the Himba, and inspiring motherhood has led to the design of a PhD (University of Central Queensland, Australia) and new forthcoming books Cultivating Mindfulness to Raise Children Who Thrive: Why Human Connection from Before Birth Matters (Routledge, 2019) and Gems of Primal Wisdom: From Before Conception Through Pregnancy, Birth and Beyond. Her PhD has been granted an International Excellence Award.

This article draws upon a chapter of Antonella’s new book and the copyrights are protected.

Antonella Sansone-Southwood

Securing the Foundations of Attachment Prior to Birth as Essential to Development A Triadic Perspective of Perinatal Wellbeing

Today we have abundant evidence of the impact of the mother’s health (physical, mental and social wellbeing) on pregnancy, foetal development, birth and the transition to parenthood to suggest the best ways to support healthy pre- and perinatal relationships and child development. The literature on maternal mental health and child behaviour indicates that both pre/perinatal and postnatal distress have significant consequences on maternal wellbeing, mother-infant bonding, and child development.

A review of 22 studies on prenatal attachment found that higher levels of mother-foetus attachment (MFA) were associated with higher family support and greater psychological wellbeing (Alhusen, 2008).

A vast literature indicates that mothers with more social support are more responsive to their babies’ needs.

In traditional societies, support from alloparents (shared childcare), which allowed our ancestors to evolve, not only improves child’s health, social maturation, and mental development but it was essential for child survival (Coontz, 1992). Other studies find correlations between a new mother’s perception of low social support and postpartum depression (Miller, 2002).

Maternal stress, included antenatal depression, can be a significant precursor of postpartum depression, couple conflicts, and the quality of mother-infant attachment (Austin et al. 2007).  If a mother is persistently stressed while pregnant, her child is more likely to have emotional or cognitive problems, such as an increased risk of attention deficit hyperactivity, anxiety, and language delay (O’Donnell, K., O’Connor, T.G., and Glover, V., 2009). Clinical accounts argue that parents’ anxieties/stress may harm the vital intersubjective bonds, birth, and development and even affect our capacity to empathize (Ammaniti and Gallese, 2014).

Antenatal psychological distress is known to impact obstetric/neonatal outcomes, which often have significant consequences on perinatal bonding, attachment and child development. Dayan et al. (2006) found that the rate of spontaneous preterm birth was significantly higher among women with high depression scores.

The long-term consequences of birth outcome have been ignored until recently, except by a small number of intuitive pioneers. Some authors argue that it is still not known what forms of anxiety or stress are more detrimental, but research suggests that the relationship between the mother and her partner is of utmost importance.

While many of us may be aware of the adverse effects of toxic substances (smoke, alcohol, drugs etc.) and acute and chronic stress on foetal development, the protective function of mother-baby relationship before birth is less known.

The mother’s emotional and mental state influences prenatal attachment towards the unborn baby, which is, in turn, a good predictor of the mother-infant relationship, as indicated by the videotaped mother-infant interactions at about 12 weeks postpartum (Siddiqui & Hagglof, 2000). 

Attuned interactions channel and enhance physical and visceral energy, thus have a neurophysiological effect and impact on infant wellbeing (Trevarthen & Delafield-Butt, 2013).

Caregivers’ early responsiveness and attunement set up the growing brain for the capacities for both self-regulating, creativity and socially attuning, thus for empathy (Siegel, 2004).  Early experiences, including prenatal, create patterns that inform human development through neural pathways, therefore human connections shape the neural connections from which the mind emerges.

A study suggests that bonding far before birth is vital for growth (Branjerdporn et. al., 2016). It follows that the quality of prenatal attachment is essential for development, for the interactions on which it is based provide and relational matrix on which the mind is created.

This evidence, resonating with the outcomes of my several years observational and clinical work with parents and infants (Sansone, 2004; 2007), provides the foundation for looking more closely at assessing and improving parental wellbeing and prenatal attachment as early as during pregnancy, ideally before conception, so that to give children a head-start before they are born.  Furthermore, it informs future interventions to support mother-unborn baby attachment and promote infant development.

Looking more deeply, this evidence indicates that the unborn baby is a sentient being capable of rudimentary engagement with maternal communication, and thus this engagement can be nurtured during intra-uterine life. It is a secure base protecting both mother and infant, therefore, it needs to be supported by the father, the meaningful people surrounding the becoming mother, including the healthcare providers and policymakers.

If the mother’s responsiveness and attuned bonding are an extension of prenatal attachment, this may show that they are a process of shared attentiveness and engagement since life in-utero. This could also explain the innate newborn’s drive for relational engagement.

On the other hands, if babies born to chronically depressed mothers show less drive for human interactions (Field et al., 1988), it may well be that babies are sensitive to a prenatal narrative and that we can promote interrelatedness in the womb through communal mindfulness.

Awareness that the preborn baby is already a psychological and social partner to his/her parents, and through them to society as a whole, must be brought to the forefront. This awareness can change the way healthcare providers relate to expectant parents and the developing baby.

It is time for the birth of a new awareness by the society that the prenatal and perinatal stages are crucial in our lives, and that not only do the mother, father and family matter, but the whole community as a vital source of wellbeing for our humanity. We need a perinatal-informed culture of kindness and compassion.

It follows that the mother (and father) needs to be nurtured through an appropriate social network and emotional support so that to foster that feeling of ‘being felt and valued’, and of ‘being alive’ that can nourish a vital embodied narrative with her baby, thus contributing to providing the best womb environment. Nurturing is about meeting an individual’s needs and human innate expectations, which we have evolved to for millions of years.

We need to support this sacred early relationship because it has profound implications, humanitarian, social and economic consequences. Every pre and perinatal healthcare professional, including psychotherapists, should adopt a mindful systemic/relational approach that considers the triad mother-baby-father at the centre.

Why paternal perinatal mental health matters

While the impact of the mother on child development has been studied widely, the role of the father and his mental health in facilitating the conditions for the mother-infant relationship to unfold has been neglected. On the other hand, our patriarch culture and social media put too much responsibility on the mother in child development, when the reality of the nuclear family already causes isolation and depression.

In the absence of the village that supported mothers through shared childcare for millennia, the role of the father in our modern society has become far more important.  A new paradigm which acknowledges the interrelational nature of human essence, the mutual influence of energy fields (quantum physics) on mental health and behaviour, which is central in primal wisdom, can help us demolish the Cartesian Western dualism which has considered the individual as a separate entity.

This same dualism has led our culture to associating qualities such as ‘rational’, ‘competitive’, ‘unemotional’ to men, at the expenses of the so-called ‘female’ wisdom qualities such as intuition, compassion, receptiveness, engagement, understanding, which are essential in intimate relationships. The catalyst wave of this awakening wave is actually collective.

It is significant that men, due to cultural reasons – sexual role and social image – are less prone to reveal their psychological difficulties (e.g. depressive symptomatology such as sadness, cry, sense of failure, impotence) and rather than asking for help they tend to somatise (develop physical symptoms), turn to smoking, alcoholism, drug, sex or Internet addiction. Or they may manifest their discomforts through aggressive and abusive behaviour. This makes more difficult to make an early assessment during pregnancy since even when asked to fill a self-report questioner, men are more reluctant to describe their psychological suffering but tend to state they feel anxious, under stress or report physical ailments. This can mask their depressive symptomatology.  

Studies on perinatal disturbances have shown that in this crucial period the mental state of fathers and mothers influence each other and can negatively impact their child’s psychomotor development. This is different from the physiological influence (higher prolactin levels and lower testosterone levels) of some men in intimate association with pregnant women or new babies, who tend to be fathers more involved in caring for the baby during the first year of life (Bronte-Tinkew et al., 2007). Studies have found a significant correlation between depression and anxiety symptoms of both and their perception of stress (Goodman, 2004; Musser et al, 2013; Baldoni, Baldaro & Benassi, 2009). If one of the partners is depressed the entire family system is compromised.

Longitudinal studies on large samples have confirmed the relationship between paternal perinatal chronic depression and psychiatric disturbances on children at the age of 7 (Ramchandani et al. 2008). A depressed father is also less involved in the care of the infant and during pregnancy less motivated in supporting pregnancy and the mother-foetus attachment. On the other hand, a father who is not affected by perinatal disturbances and is more involved in the interactions with the infant can exert a protective function against maternal depression and compensate for the poor mother-infant interactions (Edhborg et al., 2003).

This is why it is of utmost importance to value the symptomatology since pregnancy, and when one parent is depressed, consider the possibility that the other may suffer (Schumacher, Zubaran and White, 2008). The first two important protective factors in pregnancy are the mother’s relationship with the baby and the one with her partner. These need to be investigated in any prenatal program and therapy.

If we want to prevent perinatal suffering and protect the mother-infant relationship it is fundamental to acknowledge the importance of the father as early as during pregnancy if not before, support his role, identify his difficulties and promote his involvement in and contributions to the journey to parenthood. Healthcare professionals need to pay attention to the quality of the couple relationship.

Perinatal depression is often accompanied by marital conflicts, which impact on child development outcomes. In these cases, it is necessary to offer the couple a space to discuss their affective and relational problems and help them improve their relationship (Schumacher, Zubaran and White, 2008). By providing a couple relational model, parents are not only contributing to the child’s wellbeing by reducing the adverse effects of stress, but also shaping the child’s capacity to build healthy relationships.

A call for a mindfulness-based approach   

Pre and Perinatal Healthcare Professionals (obstetricians, paediatricians, midwives, nurses, psychologists, psychotherapists etc.) should train to become able to support the wellbeing of both parents throughout pregnancy and beyond and recognise the early symptomatology, often somatic, of a mental disturbance.

Mindfulness-based training will enable them to observe, recognise body signs, attentively listen, connect, understand and have compassion. In this way, they can also offer a mirror that promotes the same relational abilities within the couple and with the unborn and new baby. Couples can also benefit from a mindfulness-based course themselves, combined with therapy if needed, by enhancing the same self-regulation and relational abilities.  

Perinatal staff should train to properly inform both parents about how to recognise perinatal disturbances in themselves as well as the other, as a family biopsychosocial open system. Becoming aware of the risks and potential impact on their child development and wellbeing can help parents seek help at any stage, preferably during pregnancy. This pre/perinatal educational work can benefit from the integration with self/couple-development and mindfulness continued the practice.

Through mind-body engagement, this nurturing practice can foster reflective, stress coping, self-regulatory and relational abilities required for fulfilling parenting and secure attachment in both parents and child. Healthcare services, hospitals, and universities should organise seminars, interdisciplinary and mindfulness-based training.

One of the most interesting programs for the prevention of perinatal suffering and depression has been developed in Australia, where the prevention of maternal perinatal depression has been practiced widely for several years and the attention to the fathers is high.

This could explain why my PhD highly relevant to the prevention of perinatal depression has been accepted by two universities and been granted an International Excellent Award. The Paternal Perinatal Depression Initiative (PPDI) coordinated by Richard Fletcher (2014) of the University of Newcastle, AU, is a national program of prevention and screening of the difficulties manifested by fathers in their transition to parenting. The program is very articulated and offers, through the Internet, a series of available services not just for fathers, but all the practitioners.

My PhD design is aimed at further investigating the effectiveness of a prenatal preventive mindfulness-based relationship program I have developed for couples, enhancing their relationship and the prenatal bonding. This sacred earliest bonding is where the very roots of humanness reside, thus needs to be protected by any means. The brain changes, self and interpersonal awareness fostered by mindfulness practice promote awareness and understanding of the baby’s evolved needs and expectations and at the same time the couples’ mutual understanding and resonance.

We have supporting evidence of the benefits of mindfulness on mental, social and physical wellbeing and alleviation of anxiety and depression (Goleman and Davidson, 2017). A systematic review suggests that mindfulness-based interventions can be beneficial for outcomes such as anxiety, depression, perceived stress and levels of mindfulness during the perinatal period (Dhillon, Sparkes and Duarte, 2017). Mindfulness-based stress reduction (MBSD) has been used in antenatal classes for both parents, with the aim of preventing the negative impact that high stress and fear have on maternal and neonatal outcomes (Duncan and Bardacke, 2010).

The benefits of mindfulness extend to wisdom abilities and human treats required in parenting. Mindfulness practice fosters reflective function, intra/interpersonal attunement, receptiveness, connection with the present moment, resonance (right brain-to-right-brain communication), attentiveness and compassion, all abilities promoting attachment and fulfilling parenting (Siegel, 2007).

Studies of secure attachment and those of mindful awareness practices have overlapping findings.  In fact, both processes impact on the prefrontal cortex and amygdala activity (for emotional regulation) of the brain.  A potential outcome of my study is to inform future preventive strategies to support prenatal attachment, prevent postnatal depression, birth complications and promote infant wellbeing.

In the UK the costs associated with infant mental ill health are staggering. Perinatal depression, anxiety, and psychosis together carry a total long-term cost to society of about £ 8.1 billion for each one-year cohort of births (Mental Health Task Force, 2016). Studies have reported the huge economic impact of the healthcare costs of paternal depression in the postnatal period (Edoka, Petrov and Rachmandani, 2011).

Showing that prenatal nurturing practices such as mindfulness and mindfulness-based therapies can break the cycle of intergenerational transmission of the effects of depression has epigenetic implications. It also unleashes the potential of prenatal attachment and empowered parenting. This is also a call for healthcare professionals and science for acknowledging the prenatal relationship and adopting a compassionate approach towards mothers, fathers and sentient babies in the womb.


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