Arch Womens Ment Health (2010) 13:505513
DOI 10.1007/s00737-010-0169-z
ORIGINAL ARTICLE
The experience of labor, maternal perception
of the infant, and the mothers postpartum mood
in a low-risk community cohort
Omri Weisman & Adi Granat &
Eva Gilboa-Schechtman & Magi Singer & Ilanit Gordon &
Hila Azulay & Jacob Kuint & Ruth Feldman
Received: 30 November 2009 / Accepted: 13 May 2010 / Published online: 18 June 2010
# Springer-Verlag 2010
Abstract Postpartum negative mood interferes with
maternalinfant bonding and carries long-term negative
consequences for infant growth. We examined the
effects of birth-related risks on mothers postpartum
anxiety and depression. A community cohort of 1,844
low-risk women who delivered a singleton term baby
completed measures assessing delivery, emotions during
labor, attitudes toward pregnancy and infant, mood
regulation, and postpartum anxiety and depression.
Under conditions of low risk, 20.5% of parturient
women reported high levels of depressive symptoms.
Following Cesarean Section Delivery (CSD), 23%
reported high depressive symptoms, compared to 19%
following Vaginal Delivery (VGD), and 21% after
This study was supported by the Israel Science Foundation Grant (RF,
#1318/08) and by an independent investigator award from the
NARSAD foundation to Ruth Feldman.
O. Weisman : A. Granat : E. Gilboa-Schechtman : I. Gordon :
H. Azulay : R. Feldman (*)
Department of Psychology, Bar-Ilan University,
Ramat-Gan, Israel 52900
e-mail: feldman@mail.biu.ac.il
O. Weisman : A. Granat : E. Gilboa-Schechtman : M. Singer :
I. Gordon : H. Azulay : R. Feldman
The Gonda Multidisciplinary Brain Research Center,
Bar-Ilan University,
Ramat-Gan, Israel 52900
J. Kuint
Sheba Medical Center,
Tel-Aviv, Israel
J. Kuint
School of Medicine, Tel-Aviv University,
Tel-Aviv, Israel
Assisted Vaginal Delivery (AVGD). State anxiety was
highest in CSD and lowest in VGD. Mothers undergoing CSD
experienced labor as most negative, reported highest somatic
symptoms during the last trimester, and were least efficient in
regulating negative mood. Postpartum depression was inde-
pendently associated with higher maternal age, CSD, labor
pain, lower negative and higher positive emotions during
labor, inefficient mood regulation, somatic symptoms, and
more negative and less positive perception of fetus during last
trimester. Results demonstrate that elevated depressive symp-
toms are prevalent in the postpartum even under optimal
socioeconomic and health conditions and increase following
CSD. Interventions to increase positive infant-related percep-
tions and emotions may be especially important for promoting
bond formation following CSD.
Keywords Motherinfant bonding . Cesarean section
delivery . Assisted delivery . Postpartum depression .
Postpartum anxiety . Maternal perceptions
Introduction
The mothers negative mood, in particular maternal
postpartum depression (PPD), has long been known to
interfere with the mothers capacity to bond with her infant
(Murray et al. 1996; Martins and Gaffan 2000). PPD has
been shown to carry long-term negative consequences for
infant cognitive, neurological, and socialemotional growth
(Feldman 2007; Murray and Cooper 1997) and is associated
with increased risk for the development of psychiatric
disorders in the child (Cicchetti and Toth 1998; Murray
and Cooper 1997). Studies demonstrated that depressed
mothers are less sensitive during interactions with their
506
infants and have more negative perceptions of the infant
(Goodman and Gotlib 1999; Cicchetti and Toth 1998;
Weinberg and Tronick 1998; Feldman 2007), and this low
sensitivity predicts poorer cognitive and socialemotional
outcomes across childhood and adolescence (Murray et al.
2001; Beck 1998; Weinberg and Tronick 1998; Cooper and
Murray 2003; Kim-Cohen et al. 2005). Moreover, children
of depressed mothers are more likely to suffer depression at
some point in their lives (Cicchetti and Toth 1998;
Fombonne et al. 2001). Thus, detecting the mothers
depressed mood as early as possible in the infants life is
of central importance for maternal and infant well-being and
adaptation.
While PPD has recently gained clinical and experimental
attention, less is known about patterns of maternal anxiety
across the postpartum period or its effects on infant
development. The co-morbidity of anxiety and depression
is typically substantial (Zung et al. 1990; Brady and
Kendall 1992); yet, a history of anxiety disorders appears
to pose a greater risk for the development of postpartum
maternal mood disorder (anxiety or depression) as com-
pared with a history of major depression disorder (Matthey
et al. 2003). A failure to address the mothers postpartum
anxiety increases the rates of depression and results in
maternal sense of incompetence (Barnett and Parker 1986),
which is likely to further impair the mother-infant bond.
Given that mothers negative mood in the postpartum
tends to persist over time (OHara 1997) and to disrupt the
initial bonding between mother and child, understanding
the factors that may be associated with the mothers
depressive and anxiety symptoms in the immediate post-
partum period is of clinical and empirical importance. Thus,
the central goal of the current study was to examine the
links between the birth experience, the mothers perception
of her fetus and newborn, and the mothers negative mood
in order to specify birth-related conditions that may
interfere with the formation of the mother-infant bond.
Mode of delivery, birth experience, and maternal
postpartum mood and perceptions
The birth experience, in particular the mode of delivery, has
been associated with maternal postpartum mood and func-
tioning. Several studies indicated that various difficulties to
the motherinfant bonding process and higher risk for
postpartum mood disorders are more common and last longer
among women undergoing Cesarean Section Delivery (CSD)
or Assisted Vaginal Delivery (AVGDforceps and vacuum
extractions) as compared to women experiencing Vaginal
Delivery (VGD, Glazener 1997; Bick and MacArthur 1995;
Glazener et al. 1995; MacArthur et al. 1991; Gjerdingen et
al. 1993). Mothers undergoing CSD reported indifference to
the first contact with the infant (Garel et al. 1988) and little
O. Weisman et al.
enjoyment from the first motherinfant interaction (Cranley
et al. 1983; Tulman 1986). Swain and colleagues (2008)
found that mothers who delivered vaginally showed greater
brain activations while listening to own baby cries in key
parenting brain areas, including the superior and middle
temporal gyri, caudate, thalamus, hypothalamus, and amyg-
dale, compared to mothers delivering by Cesarean section.
Similarly, more expressions of maternal hostility and anger
were reported towards infants who were delivered by CSD
(Mercer and Marut 1981). Cesarean or assisted vaginal
deliveries are associated with diminished postpartum func-
tioning (Lydon-Rochelle et al. 2001) and a greater risk for
developing postnatal depression at 5 days after birth, 5 weeks
postpartum, and 3 months postpartum (Boyce and Todd
1992; Bick and MacArthur 1995), suggesting that the risk
posed by CSD is not limited to the immediate post-birth
hours.
In addition to mode of delivery, the mothers feelings
toward the birth experience play a role in shaping the
motherinfant bond and may be related to the mothers
postpartum mood. The mothers perception of the birth
experience predicts her later behavior toward the infant
(Ramona and Mercer 1985), and studies have shown that a
negative birth experience is associated with depressive
mood during (Rubertsson et al. 2003) and following
(Righetti-Veltema et al. 1998) a subsequent pregnancy.
Few studies, however, examined the cumulative effects of
the actual mode of delivery, the degree of pain, and the
mothers subjective emotions during labor on the mothers
postpartum negative mood.
During the last trimester of pregnancy, mothers begin to
form perceptions and become preoccupied with thoughts
and feelings toward the infant and the parenting role. Such
perceptions contain both negative components related to
anxiety and worries as well as positive components that
involve expectations of the upcoming birth and the ensuing
relationship with the infant (Leckman et al. 2004). A
longitudinal study assessing the parents negative and
positive perceptions during late pregnancy, the postpartum,
and 3 months after childbirth showed that both negative
and positive perceptions peaked in the immediate post-
partum period, along with the increases in depression and
anxiety. Moreover, increased negative and decreased
positive perceptions were associated with the emergence
of depressive mood and state anxiety (Leckman et al.
1999). It was suggested that these negative and positive
parental perceptions provide the mental environment into
which the infant is born and where the actual bonding
process begins (Stern 1995). Indeed, research has shown
that maternal cognitions and expectations during the last
trimester of pregnancy predict the nature of the mother
infant bond during the first postpartum period (Feldman et
al. 2007).
Experience of labor and maternal postpartum mood 507

The present study Table 1 Mothers demographic factors (n=1,844)

Mean SD Min Max

In light of the above, the current study examined the
associations between the experience of labor, the mothers Mothers age 30.5 4.6 21 45
perception of the infant during late pregnancy and the Mothers education (years) 14.93 2.44 12 22
newborn stage, and the mothers postpartum mood in a Fathers age 33.47 6.2 21 51
large community cohort in order to detect potential birth- No. of siblings 2.19 1.09 1 11
related risks that may be associated with elevated symp- Infants weight (kg) 3.25 0.47 3.08 5.03
toms of depression and anxiety. The experience of labor Week of delivery 39.31 1.71 36 44
was assessed both objectively, in terms of mode of delivery,
and subjectively, in relation to the mothers experience of
delivery pain and her positive and negative emotions NICU hospitalization), completed at least 12 years of
toward the experience of labor. In order to tease apart the education, and were cohabitating with the infants father
effects of birth and parental perception on PPD from those to participate in a study on maternal postpartum mood.
of other known risk conditions, such as single parenthood, Recruitments were conducted twice a week in each ward,
teenage pregnancy, and prematurity, we recruited a large and approximately 40% of the women approached refused
community sample of healthy women who delivered a participation, resulting in a final sample of 1,844 responding
singleton-term baby, were over 21 years, had at least high mothers. Hospital records showed no systematic differences
school education, and were cohabitating with the infants between mothers who completed the questionnaires and those
father. who declined or in the total percentage for mode of delivery
We hypothesized that a more negative experience of between the two hospitals. The study was approved by the
labor in terms of both objective measure such as mode of hospitals IRB, and all mothers signed an informed consent
delivery, as well a subjective report of greater pain, more form.
negative and less positive emotions, would be associated
with more symptoms of postpartum depression and anxiety. Measures
We also expected that more negative and less positive
perceptions of the infant during the last trimester would Objective measures
lead to a more negative postpartum mood. In terms of birth
complications, while unassisted vaginal delivery was Mothers were asked to report on mode of delivery.
expected to correlate with the lowest levels of depression
and anxiety, we hypothesized that CSD would exert a more Subjective measures
negative effect on the mothers postpartum mood than
AVGD. Finally, objective birth complications, subjective Mothers rated their perceived pain during delivery on a
experience of labor, and the mothers perception of the 10-point scale, and specified zny use of pain medica-
infant were expected to predict both independently and tions, and the degree to which these helped.
cumulatively the mothers postpartum negative mood.
Emotions during Labor (Slade et al. 1993) Mothers
reported on the degree to which they experienced seven
Method specific emotions during and just after birth (four positive
and three negative). Responses were averaged into negative
Participants emotions and positive emotions during birth.

The sample included 1,844 mothers who completed a set of
questionnaires regarding demographic details (Table 1),
mode of delivery, pain during delivery, positive and
negative emotions during childbirth, mood regulation,
attitudes towards the pregnancy and the baby, and anxiety
and depressive symptoms on the 2nd post-birth day.
Assistants visited the maternity wards of two tertiary care
hospitals in a large metropolitan area and invited women
who were physically healthy by their own account,
delivered a healthy term singleton infant (excluding genetic
disorders and infants requiring specialized medical care or
The BDI (Beck 1978) This widely used 21-item instru-
ment measures the level of depressive symptoms on a
three-point scale and demonstrates good reliability (Beck
and Steer 1988). Scores of 9 or above indicate elevated
depressive symptoms and a risk for MDD (Kendall et al.
1987).
The STAI (Speilberger et al. 1970) The State Trait Anxiety
Inventory (STAI) is a well-validated 40-item scale consisting
of two separate scales (20 items each) to measure stable
individual differences in anxiety proneness (trait) and current
508
(state) anxiety. Trait anxiety scores of above 43 are considered
a risk indicator for anxiety disorders.
Maternal Adjustment and Maternal Attitudes Questionnaire
(Kumar et al. 1984) This 60-item instrument assesses
maternal attitudes during pregnancy and following delivery.
The Attitudes toward Pregnancy and the Baby and the
Somatic Symptoms scales were used, which showed good
testretest and split-half reliability.
Negative Mood Regulation Scale (Catanzaro and Mears
1990) This 30-item questionnaire measures generalized
expectancies for negative mood regulation, with good
psychometric properties. The cognitive, behavioral, and
general mood regulation scales were used.
Statistical analysis
To test whether mode of delivery is linked with meaningful
differences in maternal depressive symptoms, birth experi-
ence, attitudes towards pregnancy and infant, perceived
pain during labor, and negative mood regulation, multivar-
iate analysis of variance (MANOVA) was conducted with
mode of delivery (CSD, AVGD, VGD) and infant gender as
the between-subject factors. Following a main effect for
mode of delivery, univariate analysis of variance with post
hoc Bonferroni tests were conducted. To examine possible
associations between the study variables, Pearson correla-
tion was conducted. To assess the cumulative contributions
of mode of delivery, maternal birth experience, the mothers
perception of the infant, and the mothers mood regulation
to the prediction of postpartum anxiety and depressive
symptoms, we commuted hierarchical multiple regressions
predicting depressive symptoms, state anxiety, and trait
anxiety. The large sample size provides sufficient power to
detect very small effect sizes.
Results
Prevalence on 2nd day postpartum
Overall, in this large low risk community cohort, 20.5% of
the women (n=369) reported high depressive symptoms
(Beck Depression Inventory (BDI)>9), which places them
at a higher risk for PPD. In addition, 12.5% of the women
(n=231) scored high on trait anxiety (STAI>43) placing
them at a higher risk for developing both anxiety and
depressive disorders.
Comparing the distribution of high and low depressive
or anxiety symptoms among the three mode of delivery
groups (using a 23 cross-tab analysis), it was found that
O. Weisman et al.
following CSD, 23% of the women reported high depres-
sive symptoms, as compared to 19% following VGD, and
21% after AVGD, 2 =4.44, p<.05.
Maternal postpartum mood and experience of labor
by mode of delivery
Five MANOVAs were conducted, with mode of delivery
and infant gender as the between-subject factors. These
analyses examined differences related to mode of delivery
in (a) maternal postpartum mood, (b) experience of labor,
(c) attitudes toward the infant, (d) mothers perceived pain,
and (e) mothers negative mood regulation.
Testing the three mood variables (depression symp-
toms, state anxiety, and trait anxiety), significant main
effect for mode of delivery was found, indicating that
maternal postpartum mood changed according to mode
of delivery, Wilks F (6, 3,152)= 9.32; p <.001; ES =.017.
Infants gender was found to be a nonsignificant factor in
this and all other analyses. Univariate tests showed
differences in depressive symptoms and state anxiety
scores, but not for trait anxiety (Table 2). CSD mothers
reported more depressive symptoms and state anxiety
than VGD mothers, and AVGD mothers scored higher on
state anxiety compared to VGD mothers.
A similar MANOVA conducted for mothers negative
and positive emotions during labor yielded a significant
main effect for delivery, Wilks F(4, 3,172)=25.32; p<.001;
ES=.031. As seen in Table 2, VGD mothers experienced
labor as more positive and less negative than CSD mothers
and AVGD mothers reported more negative emotions
during labor than VGD mothers.
MANOVA conducted on the mothers attitudes toward
the infant and somatic symptoms during pregnancy showed
a significant main effect for mode of delivery, Wilks F(6,
3,100)=2.11; p=.05; ES=.004. Table 2 exhibits that the
effect was related to somatic symptoms. VGD mothers
reported significantly less somatic symptoms during the
4 weeks prior to delivery than CSD mothers.
MANOVA conducted on the mothers perceived pain,
both before the use of pain medication and maximum level
of pain, yielded a significant main effect for mode of
delivery, Wilks F(4, 1,188)=42.45; p<.001; ES=.125. As
seen, the effect was related to both maximum perceived
pain level and perceived pain before using relievers. CSD
mothers reported significantly lower levels of maximum
pain during birth and before using pain medication than
AVGD or VGD mothers.
MANOVA conducted on the mothers negative mood
regulation, including the general, cognitive, and behavioral
scales, yielded a significant main effect for mode of
delivery, Wilks F(8, 2,700)=2.12; p<.05; ES=.005, but
univariate tests failed to reach significance.
Experience of labor and maternal postpartum mood 509

Table 2 Differences in maternal postpartum mood and experience of labor between delivery groups

CSD (n=530) AVGD (n=90) VGD (n=1,028) Univariate F ES

Mean SD Mean SD Mean SD

Mood
Depressive symptoms 6.64 5.00 6.48 5.05 5.83 4.77 4.87** .006 CSD>VGD
State anxiety 36.9 10.75 36.63 10.38 33.55 9.62 19.84** .025 CSD>VGD,AVGD>VGD
Trait anxiety 34.67 7.32 35.79 8012 34.66 7.68 NS
Birth Experience
Positive emotions 4.74 1.42 4.99 1.22 5.18 1.32 17.17** .02 CSD<VGD
Negative emotions 4.34 1.55 4.1 1.52 3.5 1.57 40.24** .05 CSD>AVGD>VGD
Material perceptions
Somatic symptoms 19.66 7.38 17.84 6.45 18.57 6.89 4.63*(p= .01) .006 CSD>VGD
Positive attitudes 16.67 4.68 16.39 4.73 16.93 4.77 NS
Negative attitudes 11.54 5.40 11.49 5.28 11.25 5.42 NS
Perceived pain
Maximum level 4.82 5.70 7.56 2.86 7.68 2.60 33.22** .10 CSD<VGD, CSD<AVGD
Before using reliever 5.23 3.40 7.87 2.54 8.13 1.91 83.59** .22 CSD<VGD, CSD<AVGD
Negative mood regulation
General 37.85 5.11 36.43 4.96 37.88 5.42 NS
Cognitive 34.16 5.33 34.92 5.32 34.25 5.26 NS
Behavioral 36.41 5.87 36.33 5.94 36.73 5.13 NS

*p<.05, **p<.01

Correlations between maternal mood, delivery,
and perceptions
To test the interrelationship between maternal mood,
experience of labor, attitudes toward infant, pain
experience, and negative mood regulation, Pearson
correlations were conducted. Positive emotions toward
labor correlated with maximum perceived pain (r=.10,
p< .001), and with mothers positive (r= .02, p<.001) and
negative attitudes (r = .079; p = .001) toward infant.
Negative emotions toward labor correlated with maximum
perceived pain (r=.07, p<.01), with somatic symptoms
during pregnancy (r=.13, p<.001), and with both positive
(r=.12; p<.001) and negative attitudes (r=.09; p<.001)
toward infant. Mothers positive attitudes toward infant
correlated with perceived pain before using pain medication
(r=.1, p<.01) and with maximum perceived pain during
labor (r=.09, p=.001).
Predicting maternal postpartum mood
In order to assess the contribution of birth-related con-
ditions and perceptions on maternal postpartum mood, three
hierarchical multiple regressions were performed, for
depressive symptoms, state anxiety, and trait anxiety. Based
on the literature cited above, it was expected that the
predictor variables would be related to postpartum maternal
anxiety. However, since few studies addressed predictors of
maternal anxiety on the 2nd postpartum day in a community
cohort, it was unclear whether these predictors would be
related to current anxiety (state) or a more stable form of
anxiety (trait). Thus, we computed two regression predicting
state and trait anxiety. In each model, the mothers age was
entered in the first block to control for the potential effects of
maternal age on postpartum mood and consistent with
epidemiological studies of maternal postpartum depressive
symptoms (Grote et al. 2010). Mode of delivery was entered
in the second block, maximum perceived pain during labor
was entered in the third block, and positive and negative
emotions during labor were entered in the fourth block.
Negative mood regulation was entered in the fifth block and
somatic symptoms during pregnancy and attitudes toward
infant were entered in the final block. Results appear in
Table 3.
As seen, all models reached significance. Mothers
postpartum depressive symptoms were independently
predicted by lower maternal age, less positive, and more
negative emotions during labor, lower negative mood
regulation, and both less positive and more negative
attitudes toward pregnancy and infant. Unique predictors
of state anxiety included lower maternal age, mode of
delivery, negative emotion during labor, lower negative
mood regulation and both positive and negative attitudes
to pregnancy and infant. Unique predictors of trait
510 O. Weisman et al.

Table 3 Predicting maternal depressive symptoms, state anxiety, and trait anxiety on the 2nd postpartum day

Depressive symptomsa State anxietyb Trait anxietyc

Beta R2 change F change Beta R2 change F change Beta R2 change F change

Step 1 Mothers age .09** .00 7.83** .06* .00 2.55 .013 .00 0.16
Step 2 Mode of delivery .03 .01 11.08** .10** .02 28.44** .018 .00 0.23
Step 3 Maximum perceived pain .01 .00 4.96** .02 .00 8.35** .09** .02 27.02**
Step 4 Positive birth experience .08* .06 37.58* .05 .08 48.19** .00 .05 26.78**
Negative birth experience .10* .06 37.58* .17** .07 48.19** .09** .05 26.78**
Step 5 Negative mood regulation .23** .09 122.72** .18** .08 89.56** .40** .21 310.27**
Step 6 Somatic symptoms; pregnancy .14** .10 49.14** .04 .10 40.71** .1** .06 30.71**
Positive attitudes to fetus .10** .10 49.14** .14** .10 40.71* .18** .06 30.71**
Negative attitudes to fetus .25** .10 49.14** .28** .10 40.71** .17** .06 30.71**
a
R2 Total=0.28, F(9, 1,041)=46.15, p<.001
b
R2 Total=0.27, F(9, 1,039)=43.43, p<.001
c
R2 Total=0.34, F(9, 1,037)=603.55, p<.001
* p<.05, **p<.01

anxiety were maximum perceived pain during birth, negative
emotions during labor, lower negative mood regulation,
somatic symptoms and both positive and negative attitudes
to pregnancy and infant. Mode of delivery was not a
significant predictor of trait anxiety. In combination, the
predictor variables accounted for 2734% of the variability in
the mothers postpartum depression and anxiety.
Discussion
This study is among the first to assess predictors of
anxiety and depressive symptoms in a large community
cohort of low-risk women on the 2nd day postpartum,
controlling for common co-morbid risk conditions for
PPD and focusing on potential birth-related risks for
maternalinfant bonding. Overall, our findings show that
even under optimal socio-demographic and health con-
ditions approximately a 5th (20.5%) of parturient
women report high level of depressive symptoms that
place them at increased risk for PPD.
These data accord with recent reports on the increasing
rates of postpartum depression that appear to be rising each
decade (Caplan et al. 1989), with some recent studies
indicating as much as 18% of postpartum women presenting
severe enough symptoms of depression to merit a diagnosis
of a major depressive disorder (Serretti 2006). Considering
such findings, it is reasonable to assume that when
conditions are less optimal, for instance, among teenage or
single mothers, women living in poverty or without social
support, or following premature birth, the risk for PPD
increases dramatically. In addition, our data identified several
factors that may increase the risk for postpartum depression,
including cesarean delivery, more negative and less positive
birth experience, and more negative and less positive
perceptions of the infant during the last trimester of
pregnancy and the immediate postpartum hours. Such factors
may point to specific risks for the development of maternal
infant bonding and may direct efforts to devise more specific
interventions to promote maternalinfant bonding.
While previous studies on the links between CSD and
postpartum depression have reported mixed results (Carter
et al. 2006; Lobel and DeLuca 2007), our data show that
CSD was associated with greater symptoms of depression,
with nearly a quarter of the women undergoing CSD
reporting high levels of depressive symptoms on the 2nd
post-birth day. This is consistent with studies showing that
CSD is one among several factors that place women at a
significantly greater risk for early postpartal depressive
disorder at 5 days after childbirth (Bergant et al. 1998) and
predicts higher risk for PPD at 5 weeks postpartum in
multiparous mothers (Fisher et al. 1997). In addition to
higher depressive symptoms, CSD mothers also reported a
more negative and less positive birth experience and
suffered more somatic symptoms during the last trimester
of pregnancy compared to mothers who delivered vaginally.
These findings accord with psychobiological theories of
bonding which suggest that depriving the vagino-cervical
stimulation and associated neuroendocrine patterns associated
with vaginal delivery, such as the pulsatile release of oxytocin,
Cesarean section may disrupt the emergence of the specific
behavioral repertoire and mental representations associated
with bonding in human mothers (Swain et al. 2008). Thus, by
increasing the mothers depressive symptoms, which, in turn,
decrease maternal positive investment in fetus, disrupting the
mothers birth experience, and decreasing the mothers
Experience of labor and maternal postpartum mood
positive attitudes toward the fetus, CSD may pose a specific
risk for optimal maternalinfant bonding.
It is important to note that the current findings do not
imply a causal relationship between the mode of delivery
and the mothers postpartum mood. To test such relation-
ships would require a longitudinal study that begins in
pregnancy and examine whether maternal antenatal
depression or anxiety symptoms may be associated with
an increased risk for Cesarean or AVGD, taking into
considerations psychosocial and environmental stressors.
For example, it is possible that the mothers negative
perceptions of Cesarean labor lead to a sense of failure
due to their inability to witness and participate in the
birth event (Garel et al. 1987). This, in turn, may
influence the mothers emotions toward the birth experi-
ence and shape their fetus-related perceptions which, in
turn, may exacerbate their postpartum mood and willing-
ness to invest in the newborn.
Few studies examined the mothers experience of
childbirth in relation to her mood and bonding perceptions.
The findings that both negative and positive emotions
during labor were each uniquely associated with the
mothers depressive symptoms underscore the fact that
negative and positive emotions should be addressed
separately in relation to maternal mood and the bonding
process. Similarly, the mothers experience of childbirth
was related to both her positive and negative perceptions of
the infant during the last trimester and immediately after
birth.
Another notable finding is that higher degree of
perceived pain before using pain-medications was related
to positive maternal attitudes toward the infant. Possibly,
mothers accept labor pain as a natural part of the birth
process and may even see it as a gateway to motherhood.
Perhaps higher level of pain is associated with a more
intense reward once the infant is born. The negative
correlation found between maximum perceived pain during
labor and positive maternal attitudes towards the infant may
provide additional support for this perspective.
Trait anxiety was not found to be related to mode of
delivery; yet, state anxietythe mothers current state of
anxiety on the second post-birth dayshowed a linear
decline pattern with CSD mothers scoring the highest,
AVGD mothers scoring less, and VGD mothers scoring the
lowest on current anxiety states in the immediate postpar-
tum. Similar to depression, both state and trait anxiety were
associated with the mothers negative emotions during
birth, mothers mood regulation abilities, and the mothers
positive and negative attitudes toward infant. These find-
ings further support our claim concerning the importance of
detecting and influencing mothers emotional birth experi-
ence due to its association with both postpartum depression
and anxiety. Given that maternal postpartum anxiety has
511
been the focus of little research (Swain et al. 2007), further
research is needed in order to understand the links between
maternal perceptions, birth experience, and anxiety disor-
ders in the postpartum.
Limitations Limitations of the study should be considered in
the interpretation of the findings. One important limitation
relates to the lack of information on the mothers pre-partum
mood and the associations between anxiety and depression
during pregnancy and postpartum mood. No causal rela-
tionship between the birth experience and maternal mood
may thus be inferred as it is possible that maternal
antepartum mood predicted a more negative experience.
We also did not follow mothers longitudinally and differen-
tiated those whose negative mood subsided in a short period
from those whose negative mood was more permanent.
Another possible limitation is the low risk nature of the
sample and replication in more heterogeneous samples is
needed for generalization of the findings. Yet, it is likely
that if such high proportions of depressive symptomatology
are observed among supported, healthy, and well-educated
mothers, numbers among more high-risk and unsupported
mothers would be much higher.
Clinical implications Given the fact that rates of CSD are
constantly on the rise across the Western world, as reported
in the USA, Mexico, Canada, and several European, Asian,
and South American countries (Martin et al. 2006; Kambo
et al. 2002; Lin and Xirasagar 2004; Matthews et al. 2003;
Trujillo-Hernandez et al. 2002), highlighting the risks posed
by CSD to the initial bonding between mother and child
may alert clinicians to the potentially harmful use of CSD
in cases when the procedure is not of absolute medical
necessity.
Maternal perceptions of the newborn are a central
component of the bonding constellation in human
mothers (OHara 1997); thus, factors that may disrupt
the formation of positive maternal attitudes may constitute
risk conditions for bonding. As such, enhancing the birth
experienceby reducing negative emotions and promoting
positive onesmay be an important component of interven-
tions that focus on promoting maternalinfant bonding among
dyads at risk for attachment disturbances.
Future research is required to follow the consequences of
the mothers birth experience on infants development
across childhood and beyond. Interventions to increase the
mothers positive attitudes during late pregnancy and the
postpartum and enhance the birth experience may be
especially useful for dyads that are at high risk for
attachment failures. Understanding the central role the birth
experience plays in the emergence of postpartum depres-
512
sion may alert the medical staff to attend more closely to
the mothers feeling during childbirth in order to promote a
more optimal motherinfant bond.
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