A good quality parent–infant relationship is essential to a child’s development, and the earliest experiences are crucial in establishing this foundation for success. The mother–infant bond—or formation of an intense emotional connection between a mother and her infant—is understood to lead to more positive parenting behavior as well as more optimal child development in the cognitive, linguistic, and behavioral domains.

In their bonding theory, Klaus and Kennell (1976) proposed that there is a sensitive period during the first few minutes or hours after birth when mothers and fathers must have close contact with their infants to optimize their child’s later development. Klaus and Kennell (1982) later revised their theory of parent–infant bonding, modifying their claim of the critical nature of immediate contact with the infant after birth. They acknowledged the adaptability of human parents, stating that more than minutes or hours are needed for parents to form an emotional relationship with their infants.

Bonding occurs through mutually satisfying experiences. This refers to earlier processes, through which the parent becomes acquainted with the infant, identifies the infant as an individual, and claims the infant as a member of the family.

Attachment theory was first described by Bowlby (1969), and then elaborated on by Ainsworth and colleagues (1978). Over time, positive interactions between the parent and the infant through social, verbal, and nonverbal responses (whether real or perceived) facilitates the development of secure parent–infant attachment. For an infant to attain a secure attachment to their parent, the parent must be able to provide a secure base for the infant’s exploration and a safe haven in the face of distressing stimuli.

Bonding and attachment, as essential processes in healthy parent–child relationships, both describe the importance of interaction and proximity (staying close) to the infant. This means that, insofar as is reasonable, the parent maintains proximity to the infant and responds consistently to the infant’s bids for attention that indicate needs.

With mutuality, the infant’s behaviors and characteristics elicit a corresponding set of parental behaviors and characteristics.

With acquaintance, parents use eye contact, touching, talking, and exploring to become acquainted with their infant during the immediate postpartum period. Adoptive parents undergo the same process when they first meet their new child.

Cultural Considerations

Childbearing practices and rituals of other cultures are not always congruent with standard practices associated with bonding in Anglo-American culture. Nurses should become knowledgeable about the childbearing beliefs and practices of diverse cultural and ethnic groups. Nurses need to clarify with the client and family members or friends what cultural norms they follow.

Adapting to the role of parent is a developmental transition in which parents come to terms with commitments, demonstrate growing competence in child-care activities, and become increasingly more attuned to the infant’s behavior. This can be a time of disorder and disequilibrium as well as satisfaction and joy for mothers and their partners.

For the majority of mothers and their partners, the transition to parenthood is an opportunity rather than a time of crisis. Parents try new coping strategies as they work to master their new roles and reach new developmental levels. As they work through the transition, they often develop new personal strength and resourcefulness.

Maternal sensitivity or maternal responsiveness is an important determinant of the maternal–infant relationship. It can be defined as the quality of a mother’s sensitive behaviors that are based on her awareness, perception, and responsiveness to infant cues and behavior.

Maternal sensitivity significantly influences the infant’s physical, psychologic, and cognitive development. Maternal sensitivity develops over time in a reciprocal give-and-take relationship with the infant. Maternal qualities inherent to this sensitivity include:

• Awareness and responsiveness to infant cues

• Affect

• Timing

• Flexibility

• Acceptance

• Conflict negotiation

Transition to motherhood requires adjustment for the mother and her family. Not all mothers experience the transition to motherhood in the same way. Reality-based perinatal education programs help to prepare mothers and decrease their anxiety.

During pregnancy and after birth, nurses can discuss the usual postpartum concerns that mothers experience. Nurses should plan additional supportive counseling for first-time mothers inexperienced in child care, patients whose careers had provided outside stimulation, patients who lack friends or family members with whom to share delights and concerns, and adolescent mothers. When possible, home visits should be included in the postpartum care.

Transition to parenthood brings about changes in the relationship between the mother and her partner. A strong, healthy marriage or couple relationship is the best foundation for parenthood, although even the best relationships are often shaken by the addition of a new baby.

During the first few weeks after birth, parents experience many emotions. Common issues that couples face as they become parents include changes in their relationship with one another, such as:

• Sexual intimacy

• Division of household and infant care responsibilities

• Financial concerns

• Balancing work and parental responsibilities

• Social activities

To help new parents in their transition, nurses can encourage them during pregnancy and in the postpartum period to share personal expectations with each other and to assess their relationship periodically.

Couples must schedule time in their busy lives for one-on-one conversation and try to have regular “dates” or time apart from the infant. The mother and her partner need to express appreciation for one another and their baby. Support from family, friends, and community health professionals should be identified early and used as needed during pregnancy, in the postpartum period, and beyond.

Nurses can provide opportunities for parents to discuss concerns and ask questions about resuming sexual intimacy. Sexual intimacy enhances the adult aspect of the family, and the adult pair share a closeness denied to other family members.

Changes in a patient’s sexual desire after birth are related to:

• Hormonal shift

• Increased breast size

• Uneasiness with a body that has yet to return to a prepregnant size

• Chronic fatigue related to sleep deprivation

• Physical exhaustion

Resumption of sexual intimacy seems to bring the parents’ relationship back into focus.

Partners can feel alienated when they observe the intimate mother–infant relationship, and some are frank in expressing feelings of jealousy toward the infant.

Before and after birth, nurses should review with new parents their plans for other pregnancies and their preferences for contraception.

Various factors—including age, social networks, socioeconomic conditions, and personal aspirations for the future—influence how parents respond and adapt to the birth of a child. Cultural beliefs and practices also affect parenting behaviors.

Factors that are recognized to increase the incidence of parenting problems include:

• Age (adolescent mothers or those older than 35 years)

• Same-sex parenting

• Lack of social support

• Culture

• Socioeconomic conditions

• Personal aspriations

• Parental sensory impairment 

Age

Maternal age has a definite effect on the transition to parenting. The mother, fetus, and newborn are at highest risk when the mother is an adolescent or older than 35.

Adolescence

In most cases the pregnancy is unplanned or unintended, although some adolescents do desire and plan pregnancy and childbirth. Pregnancy may be the result of sexual coercion, with the adolescent being forced to give birth.  Emotional needs of adolescent mothers often exceed those of other patients.  Adolescent mothers and fathers face immediate developmental tasks that include completing the developmental tasks of adolescence, making a transition to parenthood, and sometimes adapting to marriage. Maintaining a relationship with the baby’s father is often beneficial for the teen mother and her infant, although in adolescent pregnancy it is often found that the young father departs from the relationship.

At the same time, adolescent mothers are also dealing with a variety of other stressors:

• Stigma or rejection by their families and peers

• Dropping out of school

• Deterioration or dissolution of relationship with the biological father soon after birth, as adolescent relationships tend to be less stable

• Feeling “different” from their peers, excluded from “fun” activities, and prematurely forced to adopt an adult social role

• Conflict between their own desires and the infant’s demands, in addition to the low tolerance for frustration that is typical of adolescence, further contributing to the normal psychosocial stress of birth and parenting

Adolescent mothers and their infants are at risk for several adverse outcomes. For example, children of adolescent parents are more prone to growth and development issues, specifically language, speech, and cognitive delays, and they have an increased risk of neglect and accidental injury.  Other maternal and infantile risks include:

• Preeclampsia

• Postpartum endometritis

• Systemic infections

• Anemia

• Preterm and/or low birth weight infants

• Infants with serious neonatal conditions

• Postpartum depression (PPD)

• Substance abuse

• Posttraumatic stress disorder (PTSD)

• Intimate partner violence

• Repeat pregnancy

That being said, the majority of teen mothers have positive outcomes that are comparable to those of their peers who bear children later in life, especially when they have strong social and functional support In some families or communities.  Anticipatory guidance through developmentally appropriate education is needed to prepare adolescents for parenting. Specific topics include:

• Infant nutrition

• Growth and development

• Sleep

• Infant safety

• Immunizations

Adolescent mothers provide warm and attentive physical care; however, they use less verbal interaction than older parents, tend to be less responsive, and interact less positively with their infants than older mothers. Interventions emphasizing verbal and nonverbal communication skills between mother and infant are important.  Teenage mothers have limited knowledge of child development. They tend to expect too much of their infants too soon and often characterize their infants as being fussy. This limited knowledge can cause teenagers to respond to their infants inappropriately.  Many young mothers pattern their maternal role on what they experienced with their own mothers.  

Community-based programs for pregnant adolescents and adolescent parents improve access to health care, education, and other support services. Home visiting programs are beneficial, especially for low income adolescents. Many school-based programs include a parenting and life skills curriculum as well as pregnancy prevention strategies. Serious problems can be prevented through outreach programs concerned with self-management, parent–child interactions, infant development, and child safety.  

Family members of the pregnant or adolescent mother also need help adapting to their new roles  The vast majority of adolescent fathers do not live with the mother and infant, although many visit on a regular basis. They often are living in poverty, have limited education, and—owing to tenuous employment—have little ability to offer financial help in caring for the infant.  The involvement of the father with the infant is dependent on his relationship with the mother, who also controls his access to the infant. The father’s involvement can have a positive influence on:

• Breastfeeding

• Maternal mental health

• Parenting practices

• Family functioning as well as the child’s well-being

• Cognitive development

• Behavioral outcomes

Health care professionals should actively include adolescent fathers in care management, beginning as early as possible during pregnancy and continuing into the postpartum period and beyond. The nurse can initiate interaction with the adolescent father during prenatal visits, labor and birth, and the postpartum hospitalization. The nurse can also assess the relationship between the two adolescents and encourage them to discuss their plans for the father’s involvement with the mother and infant after birth. During the hospital stay, the nurse should include the adolescent father in teaching sessions about infant care and parenting.  Adolescent fathers need support to discuss their emotional responses to pregnancy, birth, and fatherhood. Counseling of adolescent fathers must be reality-oriented and should include topics such as finances, child care, parenting skills, and the father’s role in the parenting experience.

Teenage fathers also need to know about reproductive physiology and birth control options as well as sexual practices that lower the risk of pregnancy and sexually transmitted infections.

Advanced Maternal Age

Advanced maternal age refers to patients who give birth after the age of 35. Patients above that age have continued their childbearing either by choice or due to lack or failure of contraception during the perimenopausal years. Added to this group are patients who have postponed pregnancy because of their careers, or infertile couples who finally become pregnant with the aid of assisted reproductive technology.  Support from partners aids in the adjustment of older mothers to changes involved in becoming a parent and seeing themselves as competent. Support from other family members and friends is also important for a positive self-evaluation of parenting, a sense of well-being and satisfaction, and help in dealing with stress.

Patients of advanced maternal age can experience social isolation. Older mothers may have less family and social support than younger mothers. They are less likely to live near family, and their own parents may be unable to provide assistance or support because of their own age or health issues.  Mothers of advanced maternal age are often caught in the “sandwich generation,” taking on responsibility for the care of aging parents while also parenting young children. Social support can be lacking because their peers are probably busy with their careers and have limited time to help.  

Changes in the sexual aspect of a relationship can create stress for new midlife parents. Mothers report that it is difficult to find the time and energy for a romantic rendezvous. They attribute much of this difficulty to the reality of caring for an infant, but the decreasing libido that normally accompanies getting older also contributes.  New mothers who are also perimenopausal can experience difficulty distinguishing fatigue, loss of sleep, decreased libido, or other physiologic symptoms as the causes of the change in their sex lives.

Work and career issues are sources of conflict for older mothers. Child care is a major factor in causing stress about work. A major issue for older mothers with careers is the perception of loss of control. Older mothers are at a different stage in their careers, having attained high levels of education, career, and income. The loss of control experienced in going from the consistency of a work role to the inconsistency of the parent role comes as a surprise to many older patients. It is essential to help the older mother have realistic expectations of herself and of parenthood.  

Same-Sex Couples

Although same-sex couples experience many of the same adjustments and challenges of parenting as heterosexual couples, the transition to parenting for same-sex couples can present unique issues and concerns. For example:

• There are stressors related to identity transformation as they become parents

• They experience minority status as lesbian patients or gay men within a heterosexual parenting community and as parents within the lesbian, bisexual, gay, transgender, queer (LGBTQ) community

• If the couple is also an ethnic minority, there can be additional stress; expectations and pressures from within these communities can cause anxiety and stress and lead to feelings of isolation, alienation, and discrimination

Attitudes of health care professionals can either positively or negatively affect the care provided to same-sex couples. They are concerned about confidentiality and disclosure, discriminatory attitudes and treatment, and limited access to care.  Lesbian couples are unique in that there are two patients with maternal status, one who gave birth and the other who may be referred to as “the other mother,” “nonbiologic mother,” “co-parent,” “co-mother,” or another term preferred by the couple.  While the traditional roles of the mother and father in heterosexual relationships are well recognized, the role of the lesbian co-parent can be questioned, misunderstood, and ignored by society and by health care providers.

Intentionally or accidentally, health care providers can exclude partners or fail to acknowledge their roles in pregnancy, birth, and parenting. Integration of the co-parent into care includes offering the opportunities afforded male partners of heterosexual patients, such as “cutting the cord” and rooming in with the mother and baby during hospitalization.  Similar to heterosexual parents, lesbian couples face challenges in adjusting to life with a new baby. Lesbian couples face strong social sanctions regarding pregnancy and parenting. Lesbian parents deal with public ignorance, social and legal invisibility, and the lack of biologic connection to the child by using various techniques.  Coping techniques include:

• Carefully planning and accomplishing their transition to parenthood

• Displaying public acts of equal mothering

• Sharing parenting at home

• Establishing a distinct parenting role within the family

• Supporting each partner’s sense of identity as a mother

• Locating supportive social groups, lesbian or heterosexual

Some men in same-sex relationships, or gay couples, choose to become parents by:

• Adoption

• Assisted reproduction, in which a gestational carrier (surrogate) is impregnated by artificial insemination or in vitro fertilization

Female-to-male transgender individuals in gay relationships have been known to become pregnant.

Lack of Social Support

Social support is strongly related to positive adaptation by new parents during the transition to parenthood. Social support is multidimensional and includes:

• Number of members in a person’s social network

• Types of support

• Perceived general support

• Actual support received

• Satisfaction with support available and received

Partner support in pregnancy has a positive influence on adaptation in the postpartum period. Families and friends of new parents form an important dimension of the parent’s social network. Social networks provide a support system on which parents can rely for assistance, but they also can be a source of conflict. Grandparents or in-laws are most appreciated when they assist with household responsibilities and do not intrude into the parents’ privacy or judge them critically. A mother’s mood and fatigue in the postpartum period can be helped more by situation-specific support from family and friends than by general support.  Situation-specific support relates to practical concerns such as physical needs and child care.

Culture

Cultural beliefs and practices are important determinants of parenting behaviors. Culture influences the interactions with the baby as well as the parents’ or the family’s caregiving style. All cultures place importance on desiring and valuing children.  Knowledge of cultural beliefs can help the nurse make more accurate assessments and analyses of observed parenting behaviors. Cultural beliefs and values give perspective to the meaning of childbirth for a new mother. Nurses can provide an opportunity for a new mother to talk about her perception of the meaning of childbearing. Nurses must provide culturally sensitive care by following principles that facilitate nursing practice within transcultural situations.

Socioeconomic Conditions

Socioeconomic conditions often determine access to available resources. Parents whose economic condition is made worse with the birth of each child and who are unable to use an effective method of fertility management can find birth complicated by concern for their own health and a sense of helplessness.  Mothers who are single, separated, or divorced from their husbands or without a partner, family, and friends can view the birth of a child with dread. Serious financial problems can negatively affect mothering behaviors. Fathers who are overwhelmed with financial stresses may lack effective parenting skills and behaviors.

Personal Aspirations

For some patients parenthood interferes with or blocks plans for personal freedom or career advancement. Unresolved resentment affects caregiving activities and adjustment to parenting.  Nursing interventions include providing opportunities for mothers to:

• Express their feelings freely to an objective listener

• Discuss measures to permit personal growth

• Learn about the care of their infant (referring the patient to a support group of other mothers “in the same situation” may also be helpful)

Nurses can be proactive in influencing changes in work policies related to maternity and paternity leaves, varying models of work sharing, and family-friendly work environments.

Parental Sensory Impairment

A parent who has an impairment of one or more of the senses needs to maximize use of the remaining senses. Mothers with disabilities tend to value the importance of performing parenting tasks in the perceived culturally usual way.

• Visual impairment alone does not seem to have a negative effect on early parenting experiences. Although visually impaired parents can initially feel pressure to conform to traditional, sighted ways of parenting, they soon adapt and develop methods better suited to them. A strength that visually impaired parents have is a heightened sensitivity to other sensory outputs. One of the major difficulties that visually impaired parents experience is the skepticism, open or hidden, of health care professionals.  A visually impaired parent is denied the critical factor of eye contact in the process of establishing and maintaining a healthy parent–child relationship. A blind parent, who may never have experienced this method of strengthening relationships in the first place, does not miss it.  The infant will need other sensory input from that parent. Other people in the newborn’s environment can also participate in active eye-to-eye contact to supply this need.

• A parent who has a hearing impairment faces challenges in caregiving and parenting, particularly if the deafness dates from birth or early childhood. Whether one or both parents are hearing impaired, they are likely to have established an independent household. Devices that transform sound into light flashes can be placed in the infant’s room to permit immediate detection of crying.  Even if the parent is not speech trained, vocalizing can serve as both a stimulus and a response to the infant’s early vocalizing. Deaf parents can provide additional vocal training by use of recordings and television so that from birth the child is aware of the full range of the human voice.  Section 504 of the Rehabilitation Act of 1973 requires that hospitals and other institutions receiving funds from the US Department of Health and Human Services use various communication techniques and resources with the deaf, including having staff members or certified interpreters who are proficient in sign language.

Becoming a grandparent or a great-grandparent is most often associated with tremendous joy and happiness. It is a time of transition as roles and relationships change and new opportunities arise. Emotions are varied and can change from day to day; feelings of joy, anticipation, and excitement are often intermingled with some degree of anxiety and uncertainty.  Circumstances surrounding the pregnancy and birth influence the feelings, reactions, and responses of grandparents. Pregnancy and birth necessitate redefining intergenerational roles and relationships within the family.

The primary role of the grandparents is to support, nurture, and empower their children in the parenting role. Grandparents must acknowledge that things have changed since they first became parents as they deal with changes in practices and attitudes toward pregnancy, birth, child rearing, and men’s and women’s roles at home and in the workplace. The degree to which grandparents understand and accept current practices can influence how supportive they are to their adult children.  

At the same time that they are adjusting to grandparenthood, many grandparents are experiencing typical life transitions and events, such as retirement and a move to smaller housing, and they may need support from their adult children.  The extent of grandparent involvement in the care of the newborn depends on many factors such as the willingness to become involved, the proximity of the grandparents, and cultural expectations of the grandparents’ role.  Relationships between grandparents can change with the birth of a new baby. It is important for grandparents to respect their adult children's wishes for autonomy and respect their wishes while remaining available to help.  Grandparenting classes can be used to bridge the generational gap and help grandparents understand their adult children’s parenting concepts. The classes include information on up-to-date standards of infant care.

Increasing numbers of grandparents are providing permanent care for their grandchildren as a result of:

• Divorce

• Substance abuse

• Child abuse or neglect

• Abandonment

• Teenage pregnancy

• Death

• Human immunodeficiency virus (HIV)

• Acquired immunodeficiency syndrome (AIDS)

• Unemployment

• Incarceration

• Mental health problems