Relationships and connectedness
Image: Anna Roström / Johnér
This chapter addresses the domain of Relationships and connectedness-domain of the WHO maternal well-being framework, which emphasises supportive family and community networks, workplace policies and maternal–infant bonding during pregnancy, childbirth and early parenthood (Le Lez et al., 2025). The literature review examined factors influencing psychosocial well-being during the perinatal period. Although secure attachment and sensitive interaction are essential for child development, research findings were often parent focused. This chapter also examines the role of social support systems and effective interventions to promote relationship and peer support. The review does not cover workplace policy related matters.
Factors relating to early parent–child interaction and attachment
Attachment refers to Bowlby's (1982) description of a long-term emotional bond in which an infant seeks security, comfort, and protection from its caregiver. Bonding refers to the early feelings and emotions that a parent experiences toward their infant at the time of birth and thereafter. It facilitates parenting skills and promotes the survival and development of infant as well as later attachment and child’s sense of self (Bicking Kinsey et al., 2013). Early interaction describes the early interaction between the infant and the caregiver, including eye contact, facial expressions, touch, and rhythmic reciprocity, through which attachment and a positive early bond is formed (Grochowska et al., 2025). Together, these concepts describe how early emotional and interactive relationships are formed, but they emphasise different processes: the child's attachment, the parent's emotional bond, and early interaction.
Factors relating to early parent–infant relationship
Early parent–child interaction and attachment
Parents play a central role in shaping the infant’s developmental environment (Pontoppidan et al., 2016). Parental attachment is a set of internal behaviours fostering a close emotional bond between the parent and infant. This emotional relationship begins during pregnancy and is associated with psychosocial outcomes for both the parent and child. It is a foundational element of social and emotional development (Salehi et al., 2019).
Parenting quality, social support and the duration of parental disorders influence outcomes (Stein et al., 2014). Shorey et al. (2023) examined the significance of the biomarker oxytocin in the parent–child relationship and bonding. Their review highlights that oxytocin levels are positively associated with parental touch, gaze and affect synchrony, and that the oxytocin systems of the parent and child are interrelated. Even though findings were partly inconsistent, evidence provides a basis for families and healthcare providers to encourage more positive touch and interactive play between parents and children.
A positive postnatal experience is characterised by a mother’s ability to adapt to her new identity, develop confidence and competence in her maternal role, adjust to changes in intimate and family relationships and navigate the physical and emotional challenges of early motherhood. Achieving this sense of ‘positive motherhood,’ which includes maternal self-esteem, autonomy and well-being, is essential for both the mother and the child (Finlayson et al., 2020). The ability of parents to demonstrate warmth, sensitivity and responsiveness to their infant’s needs in the parent–infant relationship is integral to the development of the child’s future self-esteem, resilience and ability to form close relationships (Shorey et al., 2023).
Risk factors affecting early interaction and bonding
Difficulties in parent–child bonding or early interaction are often linked to various risk factors, including parental fatigue, depression and other mental health challenges (Adhikary et al., 2024; Delicate et al., 2018; Kurth et al., 2011; Ragni et al., 2020; Ramsauer & Achtergarde, 2018). Parenting quality may be impaired by depression, anxiety and PTSD and reduced maternal bonding is associated with poorer infant outcomes, including less secure attachment, difficult temperament, higher colic ratings, and less positive infant mood (O’Dea et al., 2023). After childbirth, exhaustion caused by, for example, the baby’s crying has been shown to decrease the parent’s ability to concentrate, trigger depressive symptoms, and burden the interaction between parent and child (Kurth et al., 2011).
Severe mental illnesses, including psychosis and bipolar disorder, increase the risk of impaired parenting and decrease parental sensitivity (Ramsauer & Achtergarde, 2018; Vilaseca et al., 2025). Parents with borderline personality pathology often engage in maladaptive parenting, which is linked to negative outcomes for both offspring and the parent–child relationship (Steel et al., 2019). OCD, eating disorders, substance use, parental disability and neuropsychiatric conditions further burden parenting by increasing emotional strain, reducing the parental capacity to respond sensitively, and potentially hindering bonding with the child and early parent–infant interaction (Austin et al., 2022; Burton et al., 2022; Ecob et al., 2025; Elliot et al., 2024; Elliot et al., 2024; Pingeton & Goodman, 2025).
The prevalence of mother–infant bonding problems in populations of mothers with concurrent psychiatric disorders is generally higher than in community samples. There are no formal definitions or diagnostic criteria for the presence or severity of maternal–infant bonding problems; prevalence rates are challenging to estimate. Reduced maternal bonding is associated with poorer infant outcomes, including less secure attachment, difficult temperament, higher colic ratings and a less positive infant mood (O’Dea et al., 2023).
Special circumstances
Special circumstances, such as neonatal intensive care (NICU) admissions, prematurity, low birth weight and traumatic childbirth, can further complicate the bonding process (Kutahyalioglu & Scafide, 2023). For example, the NICU environment may delay the establishment of parent–infant bonding, highlighting the need for targeted support to promote early interaction in these contexts (Siverns & Morgan, 2019).
Postpartum and birth-related post-traumatic stress disorder (PTSD) can significantly impact maternal well-being, the mother–infant relationship and child development (Frankham et al., 2023; Furuta et al., 2018). The meta-analysis by Frankham and colleagues (2023) revealed that symptoms of birth-related PTSD are negatively associated with the quality of the mother–infant relationship. The authors suggest that improving mothers’ birth experiences could play a significant role in enhancing infant mental health outcomes. In addition, trauma-focused psychological therapies (TFPT) have been explored for their effectiveness in supporting postnatal women experiencing PTSD symptoms (Furuta et al., 2018). Among mothers facing mental health challenges, positive breastfeeding experiences can mediate positive outcomes such as enhanced mother–infant bonding, increased self-esteem and a perceived potential for healing (Billings et al., 2024).
Socio-demographic and social inequality factors
Socio-demographic factors can also influence parenting skills and the quality of early interactions with the infant (Kim et al., 2025). Socioeconomic stressors, such as financial hardship, can undermine the ability of parents to meet basic needs and increase strain. This may lead to overprotective behaviours, which can also reflect real environmental risks but also be a result of parental trauma (Siverns & Morgan, 2019). These challenges are particularly pronounced in high-risk groups, where early interaction requires additional support. Parenting programmes frequently address these issues by offering guidance on fostering early bonding and interaction. These interventions are particularly important, as strained parent–infant relationships can adversely affect parenting practices and the overall well-being of the child (Kim et al., 2025). Social support and positive adult relationships may buffer some effects, but cumulative trauma tends to intensify depressive outcomes (Alvarez-Segura et al., 2014).
Paternal attachment
Paternal attachment is influenced by several key factors, including positive emotional experiences, support from partners and maternal–foetal attachment (Sun et al., 2025). Beside demographic and pregnancy-related factors (age, parity and pregnancy planning status), they reported that relationship-related factors (including marital quality, partner support and maternal–foetal attachment) are significant predictors of paternal bonding. Psychological factors such as anxiety, depression and a history of mental illness negatively influence attachment, while positive emotions have a stronger positive effect. Family income had no significant effect, which contrasts with maternal attachment research. This inconsistency may reflect cultural differences in how economic resources shape emotional engagement and unmeasured confounders such as relationship quality and mental health (Sun et al., 2025).
Social support protects the well-being of the family
Social support is one of the most significant protective factors for parents during the perinatal period. It buffers stress, promotes resilience and reduces the risk of mental health challenges such as depression, anxiety and post-traumatic stress disorder (PTSD). Support from partners, family, peers and professionals enhances emotional stability, strengthens relationships and builds parenting confidence (Silva-Fernandez et al., 2023; Xiao et al., 2021; Shorey & Chan, 2020). This chapter draws primarily on studies conducted with two-parent families; however, in the Nordic context, single-parent families form a significant proportion of all households, and their perinatal support experiences may not be fully represented in the current evidence.
A lack of support from close ones, peers and professionals has been identified in several studies as a risk factor for weaker well-being. A lack of social support is a risk factor for the development of various mental health problems during pregnancy, such as depressive symptoms during the perinatal period (Bedaso et al., 2021; Evans & Bullock, 2012; Lancaster et al., 2010, Holopainen & Hakulinen, 2019) and experiences of anxiety and stress during the perinatal period (Bedaso et al. 2021; McCarthy et al., 2021; Philpott et al., 2019). Notably, a lack of intimate partner support demonstrated one of the strongest associations with antenatal depression (Lancaster et al., 2010) and dissatisfaction in the relationship increased the risk of paternal depression (Ansari et al. 2021).
Partner support is essential for maternal and paternal mental health. It protects against depression and anxiety, contributes to a positive birth experience and promotes emotional stability during the transition to parenthood (Silva-Fernandez et al., 2023; Xiao et al., 2021; Shorey & Chan, 2020). For fathers, relationship quality and co-parenting cooperation predict paternal bonding and adjustment, while open communication and teamwork help manage stress and maintain family harmony (Sun et al., 2025; Shorey & Chan, 2020). In traumatic birth experiences and PTSD, partner involvement and emotional support are critical. Couples who face trauma together often strengthen their bond through shared coping strategies, reducing isolation and promoting recovery (Shorey et al., 2022).
Beyond intimate relationships, peer support and community connections reduce loneliness and stigma. Empathy from healthcare professionals and peer groups provides emotional security and encourages help-seeking among mothers experiencing perinatal depression or anxiety (Adlington et al., 2023; Aiyar et al., 2023). For immigrant and refugee families, social support from community networks and culturally sensitive care mitigate isolation and promote psychosocial well-being (Almeida et al., 2024; Fair et al., 2020).
Practical assistance from family members, such as help with domestic tasks and childcare, further supports parents’ daily functioning and reduces stress during the postpartum period (Fair et al., 2020). Social support also buffers the effects of intimate partner violence and other traumatic experiences, helping parents maintain emotional stability and resilience (Alvarez-Segura et al., 2014).
Adlington et al. (2023) highlighted themes illustrating the interplay between perinatal depression and loneliness, including self-isolation and concealment of symptoms driven by stigma and fear of being perceived as a ‘bad mother’. Women often report a sudden emotional disconnect after childbirth and a gap between anticipated and actual support from partners, family and the community. Pregnant women lacking support struggle to find someone to confide in or help manage distressing emotions, increasing vulnerability to stress and depression (Bedaso et al., 2021). Loneliness is compounded in disadvantaged communities by stigma and reduced access to support. Key mitigating factors include validation and empathy from healthcare professionals, peer support from other mothers and practical and emotional assistance from family members. A lack of social support or emotional isolation emerged as a central theme among pregnant women experiencing depressive symptoms and has been consistently linked to increased psychological distress across diverse cultural contexts. Despite its complex manifestations, the need for social support during pregnancy appears to be universal (Evans et al., 2012).
Strong social support is consistently identified as a protective factor for maternal perinatal anxiety and stress (McCarthy et al., 2021), postpartum depression (Silva-Fernandez et al., 2023) and positive birth experiences (Benyamini et al., 2024). It also provides relief for parents with adverse childhood experiences (Alvarez-Segura et al., 2014; Chamberlain et al., 2019). According to Atzl, Granden, Davis and Narayan (2019), social support from family and romantic partners during the perinatal period, combined with internal strengths such as self-esteem and coping ability, plays a significant protective role for women with histories of childhood abuse or neglect. Social support also facilitates help-seeking for perinatal challenges (Jones, 2019; Rouhi et al., 2019) and adaptation to changes during this period (Johnson et al., 2020; Lee et al., 2023).
In conclusion, emotional, practical or informal social support promotes resilience, protects mental health and enhances coping capacity during one of life’s most vulnerable phases. Its presence is linked to better outcomes for parents and children, while its absence increases the risk of isolation, psychological distress and impaired family functioning (Evans & Bullock, 2012; Lancaster et al., 2010; McCarthy et al., 2021).
Findings from the psychosocial intervention review for the relationship and connectedness domain
In this psychosocial intervention information portal review, a total of 21 interventions were identified as fitting in the domain of relationships and connectedness. Eight of these interventions were universal, nine targeted at-risk groups and four therapeutic interventions. Many psychosocial intervention programmes are delivered in group formats or are adapted to group-based delivery, aiming to strengthen social support (for example, COPEing with toddler behavior, Incredible years and Mellow Bumps). Similarly, programmes designed, for example, for teenage mothers often recognize the lack of social support as a critical issue. None of the psychosocial interventions in Nordic portals were directly targeted at loneliness or social isolation. However, two psychosocial interventions in UK and US portals targeted loneliness as part of broader goals (EPEC Baby and Us version, targeted at families living in areas of high social deprivation, and MOM Power, aiming to reduce multiple risks, including isolation). None of the interventions were targeted at single parents and only one mentioned challenges in the parents’ relationship as a primary goal.
Universal parenting programmes typically embed elements of peer support, although this is not always explicitly stated among the programme’s objectives. In addition, some parenting programmes aim to support the role of fathers and co-parenting skills (for example, Family foundations and Parenting together project). Nunes et al. (2021) pointed out that the transition to parenthood can be stressful, often triggering family conflicts that harm relationships and threaten the psychological health of new parents. Moreover, co-parenting interventions for first-time parents have demonstrated positive effects, for example by strengthening parent–child interactions, as well as enhancing couple communication. All parenting support programmes, as well as many risk-focused interventions, include elements that strengthen and support parent–child interaction, even when their primary objectives are broader parenting skills or goals specifically related to risk groups.
Many of the psychosocial interventions are specifically targeted at early interaction, bonding or attachment between the parent(s) and child. They aim to enhance mentalisation skills and positive interaction between a parent/caregiver and the child by strengthening sensitivity to notice and recognize the child’s needs and initiatives. Only two co-parenting programmes whose effectiveness was graded were found in the search of intervention information portals, but some programmes may be flexible in including both parents, and in this way may strengthen the parental relationship, as well as the interaction with the child. Clinicians and services practically implementing attachment-based interventions should be guided towards those interventions that have been suggested to have the most encouraging supporting evidence.
Table 9. Identified effective psychosocial interventions in Relationship and connectedness domain.
Intervention | Relationships and connectedness* | |||
|---|---|---|---|---|
Lack of social support | Challenges in relationship | Parent – child bonding, attachment and early interaction challenges | Single parents | |
COPEing with Toddler Behavior (CWTB) | X | |||
ICDP | X | |||
Incredible Years | X | |||
Marte Meo | X | |||
Mellow Bumbs | X | |||
Modified Mother–Infant Transaction Program (MITP) | X | |||
Neonatal Behavioural Assessment Scale (NBAS) | X | |||
Newborn Behavioural Observation (NBO) | X | |||
Parent–Baby Intervention | X | |||
Parent–Child Interaction Therapy (PCIT) | X | |||
Parent–infant psychotherapy (PIP) | X | |||
Supporting parent-child interaction | X | |||
Triple P – Positive Parenting Program® (Triple P for Baby) | X | |||
VIG | X | |||
Watch, wait and wonder | X | |||
EPEC Baby and Us -version (parents of babies 0-1) | ||||
Michigan Model of Infant Mental Health Home Visiting, The (IMH-HV) | ||||
Mom Power® | ||||
Parenting Together Project (PTP) | ||||
Promoting First Relationships (PFR) | ||||
IPP Infant-parent psychotherapy | ||||
*) Reminder: The selected portals only include interventions that have been evaluated within the assessment systems according to specific criteria, with an emphasis on research-based evidence of effectiveness. The interventions that demonstrate at least some research-based evidence of effectiveness are presented. The assessment systems operate dynamically, and the information presented in this report may therefore be updated quite rapidly. Regular monitoring of the relevant portals of these assessment systems is recommended (see [refer to chapter/headline]).
The checkmarks reflect what was indicated as the primary target group or objective in the portal descriptions of each intervention. Many interventions have multiple secondary goals and effects, so additional checkmarks could apply in practice.
In the literature, some approaches appeared to have a role in strengthening family and mother–infant relationships, as well as connectedness with communities and other social relationships. Many protective practices improve mother–infant bonding. For example, Karimi et al. (2020) found in their systematic review and meta-analysis that kangaroo mother care improved mother–infant attachment. They also suggested this to be taken into consideration in evidence-based decision-making by healthcare providers. Research has demonstrated that maternal–foetal attachment is positively influenced by practices such as consciously counting foetal movements (AlAmri & Smith, 2022). Women who engaged in this practice reported significantly higher maternal–foetal attachment levels than those who did not.
The effects of home-visiting preventive parenting programmes on improving the quality of mother–child interactions in early childhood have been found positive by improving maternal sensitivity and responsiveness to the baby (Alves et al., 2024). Methods using video feedback and live feedback could have benefits, since they strengthen maternal self-awareness and provide space for mothers to reflect on their own parenting behaviour (Alves et al., 2024).
According to a systematic review by Wittkowski et al. (2025), attachment-based interventions for risk groups can improve caregiver–infant relationships and their subsequent psychological outcomes, even if this is not the primary goal of the intervention. The most promising evidence was identified for the intervention programmes Attachment and Biobehavioral Catch-Up (ABC), Minding the Baby (MTB) and Circle of Security (COS) (which are targeted at risks of abuse, neglect or other high developmental risks). Bright et al. (2020) pointed out that as a treatment intervention, IPT, being effective in significantly reducing symptoms of depression and anxiety, is also effective in improving social support and relationship quality or satisfaction.
Group- and community-based approaches have a role in enabling social support and preventing loneliness. They have also been found to be beneficial for mothers with an immigrant background (Stevenson et al., 2024; Yeshitila et al., 2024). These may support feelings of social connectedness, even if the main goal of the intervention is targeted elsewhere.
Creative methods and collaborative activities can also serve as factors that strengthen the sense of belonging. There appears to be a role for arts-based interventions to be used as social support for women during the transition to motherhood in recovery from depression and to prevent isolation (Cluderay et al., 2025). Of the art-based approaches, music and singing were the most prevalent interventions employed, with all studies including this either as the main art form or as a key component within a programme of creative activities. The theme of community and peer support were the main components of these approaches, except in one study, in which participants were couples.
Key observations from Nordic expert discussions concerning the relationship and connectedness domain
Experts noted increasing polarisation in parenting experiences: some parents feel overwhelmed by expectations, while others lack basic skills such as infant nutrition and clothing guidance. Universal services remain essential for identifying infants at risk, including those exposed to negative family interactions, violence, neglect, out-of-home care, conflict‑related migration, developmental difficulties, prematurity, sensory impairments or chronic illness.
Experts noted that increased screen time among parents and families may impair their ability to respond sensitively to a baby’s cues. When attention is focused on mobile devices, a parent’s ability to detect subtle cues may be delayed. This may affect the baby’s experience of how predictable and reciprocal the interaction is. According to experts, guidance alone is not enough; families should be offered concrete ways to create moments when parents and children can focus on each other without digital distractions.
A child's temperament may act as either a risk or protective factor, and the parent–child temperament fit requires attention. Differences in temperament can manifest, for example, in a parent being calm and thoughtful while the child reacts sensitively and strongly, or vice versa. This can challenge the parent’s ability to anticipate the child’s needs or use regulatory strategies. Experts emphasized that guidance on recognising temperament traits and taking them into account in daily life can support the development of positive interaction.
Regular appointments and home visits by public health nurses offer a unique opportunity to identify families’ support needs at an early stage. Home visits allow for interaction and the observation of daily routines and potential risk factors in a natural setting. Experts emphasized that these practices require sufficient staffing resources to ensure that the workload does not compromise service quality. Additional training needs were particularly related to the assessment of early interaction, early identification of mental health issues, culturally sensitive working methods, and evidence-based interventions.
Experts stressed the need for support for basic parenting skills and more attachment‑focused interventions. Structured follow-up to strengthen early bonding was recommended, alongside broader use of approaches such as the NBO system and the Solihull Approach Antenatal Parenting Group, which require more Nordic research. Expectant fathers and non‑birth parents should be systematically included in maternal health care. Despite consensus on their importance, focus on their well-being remains limited.
Loneliness was identified as an under‑recognised issue requiring further research, particularly among single parents, socially isolated families and immigrant parents. Peer support was valued across all countries, with a need for structured, professionally facilitated groups. Strained parental relationships highlight the need for relationship support and risk identification for intimate partner violence.