Method

This is a quantitative, cross-sectional study with non-probabilistic convenience sampling. Data collection took place between February and May 2023 at a maternal and child hospital located in the city of Vitória da Conquista, Bahia. The facility provides medium- and high-complexity services to pregnant women from the southwestern region of the state, as well as psychological care by professionals in the field.

Participants

A total of 119 pregnant women aged between 18 and 45 years (M= 30.45; SD= 6.58) and gestational ages between 27 and 40 weeks (M= 32.53; SD= 4.03), all of whom were undergoing high-risk prenatal care, participated in the study. The inclusion criteria required participants to be over 18 years old and at least in their 27th week of pregnancy, as maternal-fetal bonding becomes more evident from this period onward (^{Lima et al., 2022}; ^{Rosa et al., 2021}). To be classified as "high-risk", the pregnant woman had to be diagnosed by a medical professional indicating such a condition. There were no restrictions or categorizations regarding the different conditions (e.g., hypertension, gestational diabetes) that could lead to a high-risk pregnancy diagnosis. Pregnant women with cognitive developmental delays, moderate/severe hearing loss, or muteness (aphonia) were excluded, as the instruments used do not have adaptations for the specific needs of these populations. Table 1 presents the participants' characteristics in terms of marital status, education, family support, support from the baby's father, pregnancy planning, and primiparity.

Table 1: Sociodemographic Characteristics of the Participants 

Results

The first results analyzed were the descriptive statistics of maternal-fetal attachment (MFAS-Brief Version) and the perception of parental bonding (PBI). The values are presented in Table 2. Subsequently, correlations were performed among sociodemographic variables, gestational variables, the perception of parental bond, and maternal-fetal attachment. The results are presented in Table 3.

Table 2: Descriptive statistics of MFAS - Brief Version and PBI 

Table 3: Correlations between sociodemographic variables, gestational variables, erceived parental bonding, and maternal-fetal attachment 

*p < .05

The analyses indicated weak and positive correlations of maternal-fetal attachment (MFA) with age, planned pregnancy, gestational age, and paternal care, as well as a moderate and positive correlation with support from the baby's father. Strong correlations were observed between maternal overprotection and paternal overprotection, as well as between maternal care and paternal care. Family support showed weak and negative correlations with both maternal and paternal overprotection, and a strong positive correlation with maternal care.

Subsequently, a multiple linear regression analysis was conducted with maternal-fetal attachment (MFA) as the outcome variable. To perform the analysis, it was necessary to verify the assumptions of regression. The result of the Kolmogorov-Smirnov test (p> .05) indicated the normality of the residuals, the Durbin-Watson coefficient (D) was equal to 1.993, and the variance inflation factor (VIF) values ranged from 1.04 to 1.33, indicating that the data meet the necessary criteria for the analysis to be conducted. Table 4 presents the process of variable insertion and removal using the backward method.

Table 4: Variables inserted and removed in the regression models 

^Notes: CP: Paternal Care; CM: Maternal Care; PO: Paternal Overprotection; MO: Maternal Overprotection.

The final model (6) of the multiple linear regression analysis (backward method) with maternal-fetal attachment (MFA) as the outcome variable showed a statistically significant result (F (6, 97) = 7.893; p < .001; R ² _ajusted = .287), explaining 28.7 % of the variance in MFA. The variables included in this model, in descending order of individual contribution (standardized coefficient β), were: support from the baby's father, age, primiparity, paternal care, paternal overprotection, and gestational age. The regression coefficients that comprised the final model are shown in Table 5.

Table 5: Final regression model with maternal-fetal attachment as the outcome variable 

^Notes: Outcome variable: Maternal-Fetal Attachment (MFA); PC: Paternal Care; PO: Paternal Overprotection. p < .05*

Discussion

The present study aimed to evaluate the effects of the perception of primary bonding, sociodemographic and gestational variables on the intensity of maternal-fetal attachment in high-risk pregnant women. The results indicated that the perception of overprotection and paternal care during childhood and adolescence were significant predictors of a higher intensity of maternal-fetal attachment (MFA). These findings reinforce the role of paternal involvement during childhood and adolescence, which may have repercussions in the transition to parenthood (^{Diniz et al., 2021}). Empirical studies support positive relationships between greater paternal involvement/engagement and child development, such as lower rates of behavioral and psychological problems, better cognitive functioning, and positive self-concept (Diniz et al., 2021; ^{Henry et al., 2020}; ^{Rollè et al., 2020}). Indeed, the results of this study align with other works (^{Fukui et al., 2021}; ^{Gioia et al., 2023}; ^{Handelzalts et al., 2018}; ^{Hinesley et al., 2020}; ^{Rosa et al., 2021}; ^{van Bussel et al., 2010}), although these studies did not explore the reasons or mechanisms by which memories of maternal and paternal bonds differentially affect MFA intensity. These results were also found in studies with low-risk pregnant women, indicating that gestational risk may not be a variable that affects the relationship between primary attachment and MFA (^{Cerqueira et al., 2023}).

The pregnant woman's perception of the care and overprotection received from her father may be associated with a greater presence of this figure in her life, contributing to the formation of a secure attachment characterized by feelings of safety, protection, and support. These memories can make the pregnant woman feel more prepared to offer the same care to her child, reflecting in the intensity of maternal-fetal attachment (MFA; ^{Rosa et al., 2021}). It is important to note that the roles of the father and mother may be perceived and remembered differently depending on the culture and life history of the pregnant woman. Maternal care and greater involvement are often naturalized, as mothers are traditionally viewed as the primary caregivers responsible for family well-being (^{Schmidt et al., 2023}). In contrast, the participation of fathers (paternal figures) in caregiving may be perceived as a supportive or complementary role to that of the mother, with lower cultural expectations regarding the exercise of their fatherhood and responsibilities (^{Cabrera et al., 2018}; ^{Diniz et al., 2021}; ^{Grossmann et al., 2008}). Thus, when the paternal figure assumes a more active role in caregiving and consequently has greater involvement in the life of the child/adolescent, it is possible that there is a deeper emotional and affective impact, leading to a greater appreciation of these memories during pregnancy.

The factors of care and overprotection investigated in the present study were initially described by ^{Parker et al. (1979}) in an attempt to more precisely define the construct of parental attachment, proposing that both are composed of two poles (high and low). Care is presented as the primary dimension of attachment and is characterized, at the high level, by emotional warmth, closeness, affection, empathy, and fondness, while at the low end it denotes emotional coldness, rejection, and indifference. Overprotection, in turn, is defined as control, surveillance, excessive contact, and infantilization at its high level, and at its low pole, it signals encouragement of independence and autonomy. Although high overprotection has been pointed out as a significant variable of problematic outcomes in areas of children's behavior, such as social skills, self-esteem, and mental health (^{Ferreira, 2016}; ^{Martins et al., 2014}; ^{Richter et al., 2018}; ^{Wendt & Appel-Silva, 2020}), it may be related to an important parental task: the establishment of rules and limits (^{Handelzalts et al., 2018}). This perception supports the positive influence between this factor and more intense maternal-fetal attachment (MFA), as found in the present study and in the research by ^{Fukui et al. (2021}), ^{Rosa et al. (2021}), and ^{Handelzalts et al. (2018)}.

Other explanatory models of parenting practices (^{Baumrind, 1966}; ^{Gomide, 2006}; ^{Maccoby & Martin, 1983}) indicate that high demand, positive monitoring of behavior, and consistent discipline are assertive components of parenting that influence lower levels of emotional problems, as well as higher rates of prosocial behaviors and self-esteem (^{Bhide et al., 2019}; ^{Martins et al., 2014}; ^{Weber, 2017}). Thus, despite the potential negative outcomes, paternal overprotection may also be associated with a positive perception of security, contributing to greater concern from the woman for the baby during pregnancy and, consequently, a higher intensity of maternal-fetal attachment (MFA) (^{Rosa et al., 2021}).

In turn, the influence of paternal care on MFA found in the present study aligns with other findings in the literature (^{Fukui et al., 2021}; ^{Gioia et al., 2023}; ^{van Bussel et al., 2010}). A recent research on the topic, conducted by Gioia et al. (2023), indicated that the care provided by the father was a predictor of the dimensions “assuming a maternal role” and “attributing characteristics to the fetus” of the MFA, also highlighting intergenerational transmission through epigenetics and direct observation as a possible explanation for this phenomenon. Thus, biological mechanisms, such as genetically influenced tendencies (e.g., temperament), may be modulated by the parental care received, either mitigating or enhancing these characteristics. Moreover, the observation of parental care behaviors can serve as a model for the gestational repertoire in her role as a future mother (^{Provenzi et al., 2020}). Such influences may vary in intensity depending on other social factors (e.g., stress, social support), individual factors (e.g., negative affect), and relational dynamics (e.g., family functioning) (^{Santana & Souza, 2018}). Conversely, the perception of parental rejection, which can be compared to the lower pole of care, may undermine the pregnant woman's adaptation to motherhood, influencing a sense of low competence in providing neonatal care and breastfeeding (^{Teixeira et al., 2016}).

It is indicated that the relationship developed by the pregnant woman with the primary caregiver in childhood and adolescence will extend and, consolidating throughout her life cycle, will contribute to the formation and maintenance of future bonds, relationships, and emotional states, tending to repeat or impact the construction and intensity of maternal-fetal attachment (^{Gioia et al., 2023}; ^{Trombetta et al., 2021}). It is worth highlighting that the average maternal-fetal attachment in the sample of this study was high (M= 65.98), indicating that even when the perceived parental bond with caregivers is low, it is possible for the pregnant woman to reformulate and attribute new meanings to these experiences. Therefore, the participants were able to bond positively with the fetus and develop greater adaptation to motherhood, especially with the support of the baby’s father, sustaining a non-deterministic perspective of primary attachment (^{Rosa et al., 2021}; ^{Topan et al., 2022}).

In a review study with a meta-analysis, ^{Yarcheski et al. (2009}) point out that partner support during pregnancy is an important aspect to be considered, having a moderate effect size in predicting the intensity of maternal-fetal attachment (MFA). Additionally, ^{Cuijlits et al. (2019}), in research involving 739 pregnant women, also identify partner support as the main protective factor during pregnancy and postpartum, while ^{Sacchi et al. (2021}) and ^{McNamara et al. (2019}) indicate that the quality of the marital relationship is positively associated with higher MFA. The support of the baby’s father is configured as a specific type of social support that tends to involve more affective and emotional components for the pregnant woman. It can serve as an important protective factor for the adaptation process to motherhood, reducing stress, anxiety, and ambivalent feelings that may be present, thereby promoting maternal self-efficacy (^{Campbell, 2022}). In agreement, the results of our study indicated that the variable “support from the baby’s father” had the most significant impact on the level of MFA (β = .391), reinforcing the importance of greater paternal involvement from pregnancy onwards. It is possible that the perception of this support by the pregnant woman is heightened due to the high-risk pregnancy, which, due to the context of greater uncertainty and concern regarding the child’s health, entails a greater need for paternal support, indicating a bidirectional influence relationship (^{Rocha et al., 2022}; ^{Topan et al., 2022}; Yarcheski et al., 2009).

The literature highlights the relevance of the father's role in a healthier pregnancy and postpartum experience, as acceptance of the child and support during pregnancy are associated with significant outcomes in the mother’s sense of self-efficacy and lower levels of maternal psychological distress, which could negatively impact MFA (^{Papalia & Martorell, 2022}). Paternal involvement during prenatal care can yield benefits such as improved family unity (father-mother-child), reduced anxiety and concerns regarding the pregnancy cycle, and greater clarity and acceptance of the changes brought about by pregnancy, as the partner creates a safe and welcoming environment that fosters greater interaction between the mother and the baby (^{Vieira & Aguiar, 2021}). In a review study on MFA in high-risk contexts, ^{Cerqueira et al. (2023}) emphasize social support as the main protective factor for positive attachment. Thus, the quality of current relationships and the support received may have a more substantial impact on the maternal-fetal relationship process than memories of parental attachment.

The results also indicated that gestational age positively impacts maternal-fetal attachment (MFA), corroborating other studies that suggest attachment behaviors intensify as pregnancy progresses (^{Cuijlits et al., 2019}; ^{Gioia et al., 2023}; ^{Rosa et al., 2021}; ^{Yarcheski et al., 2009}). This effect is primarily due to increased interaction between the mother-baby dyad starting from fetal movements, greater physical experiences, and the approaching delivery, making the experience of pregnancy more tangible and, consequently, reinforcing the establishment of attachment. The mother’s age was also associated with greater intensity of MFA, aligning with findings from Gioia et al. (2023), ^{McNamara et al. (2019}), and Yarcheski et al. (2009), as younger pregnant women may experience more intense ambiguous feelings about pregnancy, facing greater challenges in the adaptation process to motherhood and, consequently, in bonding with the fetus, especially in high-risk pregnancies (^{Çelik & Güneri, 2020}; ^{Cerqueira et al., 2023}).

Finally, the factor of primiparity also emerged as an explanatory variable for maternal-fetal attachment (MFA), establishing a negative relationship. Although this finding corroborates the review study conducted by ^{McNamara et al. (2019}), which indicates that multiparity is associated with a greater intensity of MFA, ^{Yarcheski et al. (2009}) report a moderate to null effect size in the relationship between parity and MFA, which supports the inconclusive nature of the relationship between these variables (^{Fukui et al., 2021}).

Conclusions

This research presents significant contributions to a greater understanding of the factors involved in maternal-fetal attachment (MFA) and the development of psychological practices. This is one of the few studies that sought to evaluate the effects of parental attachment and other variables on MFA, considering high-risk pregnancies a topic still underexplored in the national and international scientific literature with this sample, despite its relevance to public health. First, although most studies focus on the maternal figure and its impact during pregnancy, our results reinforce the importance of the father's role in development. His presence and support can make the attachment process more positive for the mother-baby dyad, contribute to a favorable adaptation to motherhood, and ultimately promote the healthy development of the child. This support can be encouraged by health professionals throughout the entire prenatal, childbirth, and postpartum processes by including partners as a target audience for public policies, such as the Partner Prenatal Program proposed by the Ministry of Health (^{Ministério da Saúde, 2016}). Such process may encompass a welcoming and inclusive stance towards men in health service environments (which are predominantly frequented by women), guidance on relevant topics in the pregnancy and postpartum processes, educational activities to prepare for the role of father, and participation during childbirth, fostering their role as caregivers and attachment figures.

Retrospectively, a woman's bond with her own father during childhood and adolescence also has a significant influence on her parenting practices, with repercussions throughout her life cycle. Our results highlight paternal involvement as an essential protective factor for the healthy development of the child, underscoring the importance of creating interventions that promote the active participation of paternal figures in childcare. Parent guidance groups specifically aimed at men, interventions that strengthen coparental relationships, and psychoeducational strategies that emphasize the relevance of paternal participation in child development are recommended as effective approaches (^{Gonzalez et al., 2023}; ^{Nascimento et al., 2022}). Research focusing on the coparental relationship, particularly the phenomenon of maternal gatekeeping, indicates that support and encouragement from the mother are crucial factors for increasing paternal involvement in the child's life (^{Altenburger, 2022}; ^{Campbell, 2022}). Such practices can be promoted in prenatal consultations and care, as well as in support groups for expectant mothers, through psychoeducation, reflections on motherhood and fatherhood, and highlighting the importance of social support to reduce overload, stress, and enhance attachment.

Regarding the limitations of this study, we highlight possible memory biases associated with the Parent Bonding Instrument (PBI), as current family support and existing parental relationships may influence the participants' recollections and responses. Furthermore, due to the inability to conduct individual data collection, the context in which the questionnaires were administered (specifically, in the waiting room of a high-risk prenatal care facility) should be considered, as some pregnant women may have felt embarrassed or, due to social desirability, avoided reporting negative experiences with their caregivers and a potentially low maternal-fetal bond. For future studies, it is advisable that data collection occurs in more private settings or is conducted by professionals who already have an established rapport with the participants to minimize these limitations.

We also recommend that new studies include samples composed of both high-risk and healthy pregnant women, with the aim of comparing levels of paternal support in both groups, as well as the involvement of fathers during their partners' pregnancies. Including the fathers of the babies or the partners of the pregnant women as participants, along with investigating their perceptions of their relationship with the pregnant woman and their bond with the baby, may contribute to a deeper understanding of the determinants and, consequently, the encouragement of this support during pregnancy. We also suggest using other psychometric instruments to reduce memory biases and broaden the understanding of the phenomena studied, such as assessing the woman's current perception of her parental bonds and the quality of the marital relationship. Thus, while the relationships between primary bonding and maternal-fetal attachment (MFA) have been explored, new studies should delve into the underlying mechanisms through which these relationships operate and are maintained (e.g., beliefs, schemas, adult attachment). It is important to emphasize that the results presented here should be interpreted in light of the specific characteristics of the sample and the collection site and are not generalizable to the entire population, as previously discussed based on the scientific literature.