Bowlby, who delivered a report on behalf of the World Health Organization, is credited with depeloping the concept of the human attachment connection. According to Bowlby, it is recommended that , infants and young children experience a warm, intimate, and continuous relationship with their mothers, a connection that allows both to find satisfaction and enjoyment [1]. For mothers and their children, a lack of attachment ties may have permanent health effects [2]. Critical elements related to the attachment relationship are continuously being researched despite the theory’s long history.

Attachment between the mother and the baby begins before birth, when the woman finds out she is pregnant. This type of attachment is scientifically called maternal-foetal attachment. In 1981, Cranley defined it as the extent to which women engage in behaviours that represent an affiliation and interaction with their unborn child [3]. This definition by Cranley is adopted in the present study as well.

Moreover, Cranley developed the first instrument for measuring maternal-foetal attachment, which is one of the most used in this topic—the Maternal-Foetal Attachment Scale (MFAS). Herein, MFAS inversion adapted and validated in the Romanian context has been employed. More information will be provided in the methodology section.

Pregnancy is a time of transition, mainly for women, which brings about changes in identity, relationships, emotions, and physical health [4]. The attachment relationship plays an essential role in the psychological definition of the individual. It is a court essential in the prenatal period because it dictates how the future child’s personality will be developed [5]. The attachment bond is the mechanism through which nature ensures the survival of the species. The oxytocin hormone plays an extraordinary role in the attachment bond. Oxytocin and prostaglandins help stimulate contractions in pregnant women at birth. They also soften the cervix and help with placental separation and expulsion after birth. Oxytocin also causes milk to be released from the mammary glands, and its level increases when the mother touches her infant. In addition, it enhances neocortical development, cortical blood supply maintenance, and maternal behaviour [6].

The relationship between a mother and her unborn child intensifies as the woman may begin to feel the movement of the foetus inside the uterus starting from 16 weeks of pregnancy [7, 8]. Additionally, during this time, the pregnant woman starts to imagine some aspects of the baby, such as their personality or physical characteristics [9, 10]. This idea that the foetus is a human being strengthens the pregnant mother’s attachment to the child.

The psychological bond that forms between the mother and the unborn baby is a set of thoughts, emotions, desires and expectations [11, 12]. Only 10–15% of women do not develop a bond with their baby by the third-trimester [13]. Bonding impairment appears to remain stable across the antenatal and postnatal periods [10] and predicts lower responsive and sensitive parenting, insecure mother-infant attachment, and mental health problems in children [14, 15]. Assuming the birth process and the attachment bond develop naturally without any impediments, the mother and her baby are wholly coordinated; their heart and breathing rhythms synchronize, and brain frequencies slow down to the Theta level. The process of birth can then be natural and gentle. Therefore, it is crucial to understand the low pregnancy acceptability of antenatal bonding.

Higher degrees of maternal-foetal attachment have been linked to several factors like receiving family support and improving psychological health [16], ultrasound visualization of the fetus using modern technologies [17], women with previous pregnancy loss [18], or fetuses with anomalies [19].

The goal of the current study is to determine the impact of a mother’s mental health, socio-economic contexts, and characteristics on maternal and foetal well-being, considering the importance of developing an attachment bond as early as the prenatal period. Thus, we formulate the following hypotheses:

H1: There is a correlation between the level of maternal-foetal attachment and the level of depressive symptomatology.

H2: There is a correlation between the level of maternal-foetal attachment and the level of anxious symptomatology.

H3: There is a correlation between the level of maternal-foetal attachment and the level of stress.

H4: There are differences in the level of maternal-foetal attachment between women who have an urban residence and those who have a rural residence.

H5: Women with higher education (bachelor’s, master’s or doctoral studies) have a higher level of maternal-foetal attachment than those without higher levels of education.

H6: Younger women under 30 years of age have a higher level of maternal-foetal attachment than women over 30 years of age.

H7: There are significant differences in terms of maternal-foetal attachment depending on the level of socio-economic conditions.

After analysing the sociodemographic details of the expectant mothers, it was found that 50% were between 18 and 30 years old and 50% were over 30. Most patients came from urban areas (60%); 35.5% had high school education, but a similar percentage (32%) had graduate school education. Working conditions were approximated to low-risk in 55% of cases; only 1 patient declared high-risk working conditions. The socio-economic conditions were appreciated as good, satisfying and very good in most cases. In 8.5% of the questionaires, the patients stated that they live in poor socio-economic conditions (Table 1).

In the analysis of the data from the MFAS, DASS-21-D (Depression Anxiety Stress Scale, Depression subscale), DASS-21-A (Depression Anxiety Stress Scale, Anxiety subscale), DASS-21-S (Depression Anxiety Stress Scale, Stress subscale), 4 extreme scores were identified and subsequently eliminated from the statistical analyses. Therefore, 196 responses were analyzed in the correlation analyses. After the elimination of the 4 extreme scores, the distribution of the data turned out to be normal, with the Skewness values falling within the normal limits [–2; 2] [23].

We performed two-way Pearson correlation to test the correlation between maternal-foetal attachment and depression. In making this correlation, we used scores from the MFAS and depression subscales from DASS-21. A statistically negative and insignificant relationship was identified (r (194) = –0.04, p = 0.53, p $>$ 0.05). We performed two-way Pearson correlation to test the correlation between maternal-foetal attachment and anxiety. In order to perform this correlation, we used the scores from the MFAS and anxiety subscales from DASS-21. A statistically negative and insignificant relationship was identified (r (194) = –0.12, p = 0.09, p $>$ 0.05). We performed two-way Pearson correlation to test the correlation between maternal-foetal attachment and stress. In order to test the materno-foetal attachment, we used the scores from the MFAS and stress subscales from DASS-21. A statistically negative and insignificant relationship was identified (r (194) = –0.04, p = 0.51, p $>$ 0.05) (Table 2).

We used the independent sample t-test for hypotheses 4, 5, and 6. 1 extreme score was found throughout the data analysis process, and it was removed from all statistical analyses. As a result, the comparison analysis examined 199 replies.

To find out if there are any variations in the degree of materno-foetal attachment between women who live in urban areas and those who live in rural areas, we used the t-test for independent samples. The group with urban residence (N = 119, mean (M) = 84.65, standard deviation (SD) = 9.22) and the group with rural residence (N = 80, M = 86.16, SD = 8.58) do not differ statistically significantly (t (197) = –1.18, p = 0.24, p $>$ 0.05). Next, we applied the t-test for independent samples to determine if there are differences in the level of materno-foetal attachment between women with higher education and those without. There were no statistically significant differences t (197) = 0.45, p = 0.63, p $>$ 0.05 between the group with higher education (N = 120, M = 85.48, SD = 9.61) and the group without higher education (N = 79, M = 84.91, SD = 7.98).

Next, we tested if there were any variations in the degree of maternal-foetal attachment between women under 30 and those over 30 using the t-test for independent samples. Between the group under 30 years old (N = 109, M = 84.93, SD = 9.22) and the group over 30 years old (N = 90, M = 85.66, SD = 8.72), there are no statistically significant differences (t (197) = –0.57, p = 0.56, p $>$ 0.05).

Table 3 shows no statistically significant differences in the comparison analyses regarding MAFS.

To test the hypothesis 7, we used the ANOVA test. The participants were divided into the following groups: with poor socio-economic conditions (N = 17), satisfactory (N = 85), good (N = 81), and very good (N = 16) (Table 4).

The results (Table 5) indicate that there are significant differences between the 4 groups, F (3, 1950) = 2.99, p = 0.03, p 0.05. The highest level of maternal-foetal attachment was identified in the group with satisfactory socio-economic conditions (M = 86.14, SD = 8.79), followed by the group with good conditions (M = 86.02, SD = 9.22).

This study aimed to evaluate maternal-foetal attachment during the second- and third-trimesters of pregnancy, and how it can be influenced by the mother’s mental health, socio-economic context, and demographic data such as age, residence, and education in a city in western Romania.

Some recent studies suggest a relationship between depression and anxiety during pregnancy and maternal-foetal attachment. Hart and McMahon found that women with low-quality maternal-foetal attachment reported significantly higher levels of anxiety and depression [24]. However, our study found no correlation between prenatal attachment scores, depression, anxiety, and stress.

Furthermore, no significant correlation was found between maternal-mental health and MFAS. This result suggests that pregnant women usually adapt to the changes occurring during pregnancy. However, Abasi et al. [25] indicated that high levels of prenatal attachment bond were related to less anxiety, stress, and depression, thereby contributing to better female mental health. Some pathologies associated with pregnancy, such as hypertension, diabetes mellitus, can influence maternal-foetal attachment [26]. The foetal malformation can cause stress, which can influence the mother-child relationship. In our study, no foetal malformation was identified.

Research has suggested that prenatal attachment bond motivates good health practices during pregnancy, facilitates adaptation to the role of parenthood, and may even serve as a protective factor against perinatal depression. This theoretical approach to pregnancy is deemed necessary across the disciplines of medicine, psychiatry, and social work, both academic and clinical [5].

Research shows that no significant relationship exists between the mother’s age and the level of prenatal attachment throughout pregnancy [27]. Malm et al. [28] identified that pregnant women in the younger age group showed higher levels of prenatal attachment than those in the older age group. However, in studies by Rubertsson et al. [29], women over 25 showed low attachment. Our study did not identify a significant difference regarding the age level and the relationship between maternal-foetal attachment.

In our study, following the comparisons between the economic status and the MFAS, it was found that the extremes (very good and poor socio-economic conditions) fall in the developed attachment category. Regarding pregnant women with satisfactory and good incomes, the attachment bond advocates for very well-developed socio-economic conditions. Following these results, it was concluded that moderate incomes positively influence the attachment scale. Pregnancy-related income status and mother-infant bonding have not been linked, according to similar research [30].

In terms of differences in the level of maternal-foetal attachment based on the level of education, the results of the current study do not report a significant difference. According to studies by Ustunsoz et al. [31], prenatal attachment bonding and education have been found to correlate positively. Furthermore, these authors claimed that prenatal attachment bonding was reduced in women with less education.

A study based on Hungarian women proposes a two-factor structure of maternal-foetal attachment to distinguish between behavioural and mental components of the maternal-foetal relationship. The result shows that maternal attachment to their fetuses is not significantly influenced by psychosocial traits or socio-demographic status [32]. On the contrary, some studies have shown that pregnant women who were financially secure, worked, had children of the desired sex, and received support from their husbands during pregnancy exhibited higher levels of attachement during pregnancy. An important conclusion is that it is possible to identify mothers and newborns at risk by understanding the variables that influence attachment and assessing the degree of attachment in expectant mothers [33].

Prenatal attachment theory is essential to academic and clinical medicine, psychiatry, and social work, as research indicates that it promotes healthy behaviours during pregnancy, helps with adjusting to the role of parenthood, and may even act as a protective factor against perinatal depression [5]. Digital technology offers facilities for creating educational applications intended to guide specialists from different medical fields [34, 35]. Considering the multidisciplinarity of the topic addressed, the development of dedicated computer applications could positively impact the management of these cases. Studies prove that the fact that the patient sees the ultrasound images of the fetus has a good influence on the postpartum mother-child relationship. The generation of virtual reality images that present the fetus in a form as close as possible to reality has been proven to increase maternal-foetal attachment [36].

This study highlights the importance of social and mental health factors related to the attachment bonding between the mother and the unborn child. We concluded that social factors such as age, level of education, socio-economic conditions, and residence do not statistically significantly influence the scale of maternal-foetal attachment. However, the mother’s mental health did not significantly correlate with the attachment bond evaluated by MFAS. In our study, prenatal attachment bond scores, depression, anxiety, or stress were not correlated.

PIF, Personal Information Form; DASS-21, Depression Anxiety Stress Scale 21; DASS-21-D, Depression, Anxiety and Stress Scale, Depression subscale; DASS-21-A, Depression, Anxiety and Stress Scale, Anxiety subscale; DASS-21-S, Depression, Anxiety, and Stress Scale, Stress subscale; r, correlation coefficient; p, level of signification; MFAS, Maternal-Foetal Attachment Scale; COG, Clinic of Obstetrics and Gynecology; PBCCEH, “Pius Brinzeu” County Clinical Emergency Hospital.

All datasets are available by e-mail to the corresponding author.

Conceptualization, DM and BCB; Acquisition, MC, AG and ABC; Analysis, VE, AL and VB; Investigation, LH and AP; Resources, AP, VB and BCB; Interpretation, BCB, DL, EB; Writing—original draft preparation, VE, ABC, BCB, DM, AG, AL and EB; Writing—review and editing, LH, VB, EB, DL, AP and MC; Visualization, AG and AL; Supervision, EB; Project administration, DL. Finally, all authors read the article and approved publishing the final version. Each author has agreed to be responsible for all aspects of the work, ensuring that questions about the accuracy or integrity of any part of the work are appropriately investigated and resolved.

The ethics committee of PBCCEH agreed that the study should be carried out within the medical unit (266/22.09.2021). Permissions were also obtained from the Scientific Research Ethics Commission of “Victor Babes” University of Medicine and Pharmacy, Timisoara (47/01.09.2021). Written consent was received after informing participants regarding the purpose of the study before filling in the questionnaires.

Acknowledge for the administrative and technical support of our colleagues and students who collaborate in the article elaboration.

This research received no external funding.

The authors declare no conflict of interest. Marius Craina and Elena Bernad are serving the Guest editors of this journal. We declare that Marius Craina and Elena Bernad had no involvement in the peer review of this article and has no access to information regarding its peer review. Full responsibility for the editorial process for this article was delegated to George Daskalakis.