Pregnancy marks a period of emotional, physical, identity and relational changes that are largely shaped by women’s individual circumstances (1). For some women, learning of a pregnancy is an overwhelmingly positive experience. For others, it may evoke fear and anguish; or feelings of shock, surprise or ambivalence (2, 3). Pregnancy acceptability is a term used to describe how a woman thinks and feels about a pregnancy once she learns of it (4). The concept of pregnancy acceptability aims to captures a woman’s appraisal of the desirability and timing of the pregnancy after conception (5). Previous frameworks have used a pregnancy intendedness model, founded on a planned versus unplanned dichotomy, to identify women at risk of mental health and early bonding difficulties (6). Given the complex trajectory of pregnancy emotions and experiences, a dichotomy based on initial reproductive intentions may be limited for understanding and supporting pregnant women (7, 8). In this article, we explore whether a woman’s response to pregnancy, that is, her assessment of pregnancy acceptability, is associated with maternal mental health and bonding during pregnancy.
The pregnancy intendedness model holds that pregnancy can be categorised as intended, mistimed or unwanted, with the latter two groups forming an umbrella category of ‘unintended’ pregnancy (9). International research suggests that approximately half of all pregnancies (10), and 40% of pregnancies that are continued to birth, are unintended (11–13). Unintended pregnancy is associated with delayed antenatal care and fewer health-related behaviours during pregnancy for mothers (14, 15), as well as increased risk of need for neonatal special care after birth, breast-feeding difficulties (16), and mental health and behavioural problems in children (17). For these reasons, the intended or unintended nature of women’s pregnancies has been an area of sustained research attention over the last 20 years. Some studies have found that women with unintended pregnancies find it more difficult to establish a bond with their baby (18, 19) and maintain good mental health (14, 15) during pregnancy, however other studies have not found significant results (20–22).
Although the straightforwardness of the intended versus unintended pregnancy dichotomy is valuable, it has also been subject to criticism for over-simplifying the complexities of pregnancy (23, 24). The intendedness model requires assumptions to be made about women’s reproductive decisions when planning does not occur and does not account for circumstances in which a pregnancy may not be planned but welcomed (8). In particular, the model may be insufficiently sensitive to individual differences in women’s attitudes towards their pregnancy (7) as it does not account for feelings of ambivalence often reported by women (24, 25) and the fact that many women report varying attitudes towards intendedness throughout their pregnancy (26). Awareness of these limitations has prompted a reconsideration of whether pregnancy intendedness provides a sound basis for clinical decisions in identifying women in need of support (27). One concept that has emerged to address this gap is pregnancy acceptability (4).
Pregnancy acceptability is defined as the degree to which women consider their pregnancy ‘acceptable’ after conception (28). It takes into account a women’s appraisal of the desirability and timing of the pregnancy (5), the congruence of pregnancy intentions and fertility-related behaviours (24) and the range of emotions experienced when she learns of the pregnancy (24). The pregnancy acceptability framework acknowledges that a woman’s intentions and feelings towards her pregnancy may be multi-dimensional and incongruent (29, 30). This aspect of the model is supported by empirical research which suggests that 68% of women describe their unintended pregnancy as “wanted” (31) and that women report rewarding parts of unintended pregnancy such as improvement in partner relationship, recognition of resilience and avoiding waiting for the “perfect time” to have a baby (32). A recent study found that couples based their pregnancy acceptability on factors such as relationship stability, feeling prepared to and capable of being a parent and taking a flexible approach towards family planning (7). These studies highlight the value of understanding women’s cognitive and emotional responses to pregnancy. They suggest that the way a woman feels in response to learning of a pregnancy may impact upon the way she feels towards herself, her baby and the emotional bond that develops between the dyad.
The emotional bond between a mother and her infant begins during pregnancy and marks the origins of the mother-infant relationship and the foundation for future interactions (33). Antenatal bonding, initially described as maternal fetal attachment, was introduced by Cranley (34) to describe the behaviours pregnant women engaged in that marked a desire to interact with and form a relationship with their unborn child. Antenatal bonding exclusively focuses on the affective tie from mother to baby (35, 36) and is made up of thoughts, behaviours and feelings (37, 38). Approximately 10–15% of women do not develop a bond towards their baby by the third trimester (39). Bonding impairment appears stable across the antenatal and postnatal periods (35, 40) and predicts lower responsive and sensitive parenting (41), insecure mother-infant attachment (42) and mental health problems in children (43). Therefore, it is important to understand whether low pregnancy acceptability may inhibit antenatal bonding.
Developing an emotional connection to one’s baby may prove to be particularly challenging for the one in five women who experience mental health difficulties from conception to one year postpartum (44). A study by McConachie and colleagues (45) found that 40% of women rated their wellbeing as poor during the transition to motherhood. This is especially significant because poor mental health during pregnancy is associated with impaired antenatal bonding (18, 39) perhaps due to a lack of emotional resources, beliefs about poor parenting competency, and negative attitudes towards caregiving (46, 47). Depression has consistently been shown to be associated with lower antenatal bonding (48, 49). Anxiety has been found to be negatively associated with antenatal bonding quality, while inconsistent findings have been reported in relation to antenatal bonding as a global construct (50, 51). A small number of studies have found that women with higher stress (52, 53), lower subjective wellbeing (54) and positive affect (55, 56) report lower antenatal bonding. To date, no studies have been conducted to examine the potential role of pregnancy acceptability in maternal mental health and antenatal bonding. It may be that pregnancy acceptability can help to explain the relationship between maternal mental health and antenatal bonding. If women with low pregnancy acceptability are more vulnerable to the stressors of pregnancy, we might expect to see an association between distress and bonding for these women in particular.
The period following confirmation of pregnancy represents a significant transition period and is likely to involve an appraisal of a wide range of factors including desirability, suitability of timing, implications for identity, achievement of goals and alignment with values. Being able to capture the way women think and feel about their pregnancy, in addition to understanding their pregnancy intentions, may be useful in supporting women’s mental health and early mother-to-baby bonding. In this paper, we examine the role of pregnancy intendedness and acceptability in mental health and bonding during early pregnancy in a community sample of Australian women. We hypothesise that women with low pregnancy acceptability will report higher distress, lower wellbeing and lower antenatal bonding. We will also explore whether pregnancy acceptability moderates an association between maternal distress and antenatal bonding, but given a lack of existing research, no specific hypotheses were made.