Perinatal Maternal Attachment in Bangladesh: Understanding Determinants and Impacts of Enhanced Nutrition and Cash Transfers

Background The caregiver-newborn attachment is vital for children's cognitive and socio-emotional development. Social protection programs, such as cash and food transfers, may enhance maternal attachment by reducing financial stress and strengthening marital relationships. However, causal evidence on the impact of these interventions on attachment and its correlates is lacking in low- and middle-income countries. This study examined 1) whether adding fortified food baskets or top-up cash to Bangladesh government’s Mother and Child Benefit Programme (MCBP) improves maternal-fetal and maternal-infant attachment, 2) whether the interventions' impact on attachment was mediated by changes in food insecurity, maternal stress, intimate partner violence, and women’s attachment to their husbands, and 3) the concurrent and lagged correlates of perinatal attachment. Methods Using the longitudinal data of a cluster-randomized trial in six rural subdistricts in Bangladesh, we recruited 4,609 MCBP-eligible pregnant women (second trimester) aged 20–35, from poor households, and in their first or second pregnancy. Study clusters (N=144) were randomly assigned to one of three arms: 1) Standard MCBP (~7.40 USD monthly cash transfer and nutrition education), 2) Standard MCBP + fortified foods (during pregnancy), or 3) Standard MCBP + top-up cash of ~9.25 USD (during pregnancy). Data were collected during the second trimester (at study enrollment), the third trimester, 72 hours after birth, and two months postpartum. Maternal-fetal attachment was assessed in the third trimester using the Prenatal Attachment Inventory. Maternal-infant attachment was assessed at two months postpartum using the Postpartum Bonding Questionnaire. Intervention impact was estimated as the difference in mean scores between arms using cluster-adjusted mixed-effects regression. All analyses were intent to treat. Sobel’s test assessed mediation, and multivariable regression examined attachment correlates. Results Enrollment characteristics were similar across study arms. Neither intervention affected maternal-fetal attachment scores. Maternal-infant attachment, however, was better in women who received food transfers during pregnancy than women in the comparison arm (geometric mean ratio:1.36, 95% CI: 1.07-1.71, p=0.01), with positive effects on the subscales impaired bonding, infant-focused anxiety, and rejection. No effect was found in the top-up cash arm. Mediation analysis found no indirect effects of the interventions on attachment outcomes through the selected mediators. Multivariable regression showed food security, adequate mobility, and avoidance from the husband were linked to stronger prenatal and postpartum attachment (both concurrently and when experienced earlier in pregnancy). Better household wealth, higher education, and internal locus of control were associated with stronger prenatal attachment. Maternal stress had contrasting effects—higher stress strengthened prenatal attachment but weakened postpartum attachment. Conclusions Fortified foods with a base cash transfer during pregnancy improved maternal-infant attachment. The lack of effect in the top-up cash arm could be related to cash being used by others and for purposes unrelated to maternal and infant health, warranting further research. The correlates underscore the need to provide supportive resources to women in low- and middle-income countries while addressing socioeconomic and psychosocial challenges to enhance maternal attachment and foster children's socio-emotional development.