Perinatal anxiety and compromised bond: A qualitative study of cultural scripts, structural barriers and maternal emotional negotiations in Pakistan

Abstract

Maternal-infant bonding is essential for early development and long-term well-being. In low-resource settings like Pakistan, perinatal anxiety, though prevalent, remains under-recognized and can significantly disrupt bonding. While perinatal depression has garnered greater research attention, the cultural and relational dimensions linking anxiety to bonding remain underexplored. This qualitative study examined how maternal distress, sociocultural expectations and healthcare limitations influence bonding. Eighteen pregnant and postnatal women (aged 19-45 years) with clinically significant anxiety (Generalized Anxiety Disorder 7-item scale ≥ 10) were purposively recruited from public hospitals in Rawalpindi and Islamabad. In-depth interviews were conducted in Urdu and analyzed using Braun and Clarke's thematic analysis. Five major themes emerged: (1) emotional vulnerability during the perinatal period, (2) interpersonal and family dynamics, (3) maternal health and role strain, (4) cultural scripts and structural barriers and (5) participant-driven recommendations. Anxiety often delays emotional connection. Judgment, limited autonomy and lack of support worsened distress, while faith, rituals and relational coping offered resilience. This study provides novel qualitative evidence that perinatal anxiety and maternal-infant bonding are co-constructed within the relational and sociocultural ecologies of low- and middle-income countries like Pakistan. Findings challenge purely symptom-focused approaches, underscoring that effective intervention must address not only the emotional invisibility of mothers but also the relational pathways of distress, such as hypervigilance, exhaustion and performance anxiety, which are intensified by a lack of respect, autonomy and validation. A shift toward contextually grounded, relationship-centered care is urgently needed.