One of the most important relationships in any child's life is that shared with his or her primary caregiver, usually the child's mother. This is changing in contemporary Gulf Cooperation Council (GCC) countries. With increasing national wealth leading to changes in lifestyle, more families now hire maids, often recruited from overseas, to assist in daily chores, which may include child-rearing. This ability to employ maids has provided a freedom not hitherto experienced by these households. Consequently, an increasing number of children are now raised by maids, even where non-working mothers are at home. Career responsibilities may also conflict with maternal duties, by resulting in fewer hours of contact between mother and child. Although statistics are not available, the clinical impression perceived by one of the authors of the present study during routine paediatrician practice supports this assumption. The present study examines the level of involvement that maids have in day-to-day family life, and whether this has any effect on the strength of the mother–child attachment or bonding.
Attachment, as defined by the classic study by Bowlby (reviewed by Bretherton1), is a basic behavioural system whereby the child seeks the sanctuary provided by his or her mother through the establishment of an intimate mother–child relationship. Previous studies have demonstrated that the absence of this relationship has devastating consequences for children's emotional health.2
The goals of this research were (a) to conduct a pilot study investigating the increasing dependence of Saudi mothers on maids to assist them with the upbringing of their children; (b) to investigate the level of mother–child attachment in the presence of a maid; and (c) to study the prevalence of breastfeeding. The hypothesis being tested was that the involvement of maids in child-rearing affects levels of mother–child attachment. The roles that maids play in society have not been documented in Saudi Arabia, nor perhaps in the GCC countries generally, and thus the findings of this study could have relevance to the entire GCC Arab community.
Materials and methods
A descriptive cross-sectional study was designed in consultation with an epidemiologist, and was conducted in Riyadh, Saudi Arabia. A convenience sample was recruited from three different tertiary hospitals and shopping centres by health educators and case managers not involved in the study. In total, 500 questionnaires were distributed, 336 of which yielded complete data sets. The inclusion criteria of the sample included living in Saudi Arabia and having one or more children of at least 1 year of age.
Two measures were administered for the study. First, the Demographic Data Sheet (DDS) was developed. The DDS records information such as age, nationality and education level, and addresses the maid's role within the household and the frequency of breastfeeding. All answers submitted were subject to statistical analysis. The questionnaires were translated from English into Arabic and back by a panel of bilingual experts. This instrument is valid and reliable, and has a Cronbach's alpha value of 0.84. Moreover, the content validity of the revised version of the DSS was established by national experts, and the construct validity was established using exploratory factor analysis.
The study was approved by the Institutional Review Board of the King Fahad Medical City. Participants were identified and provided with information regarding the significance and the purpose of the study. Verbal consent was then obtained. The participants were assured that participation was voluntary and that their responses would be treated in confidence. They were also informed they were free to withdraw at any time. Anonymity was advocated in all aspects of data collection. The participants' identities was neither requested nor required. The questionnaire was designed to enable completion within 5–10 minutes.
Completed questionnaires were collected by the researcher and the data analysed and recorded as descriptive statistics. The study investigated the association between the number of maids in a household (and their responsibilities) and a mother's choice of bottle-feeding over breastfeeding. The study also analysed the relationship between levels of mother–child attachment and the presence of a maid, using a mother–child attachment scale. In addition, any association between the duration, or exclusive use, of breastfeeding and the employment of a maid was analysed.
The study recruited 336 mothers with at least one child of least 1 year of age. The mean age of the participants was 33 years; the average age at marriage was 21 years. The majority of the mothers were married, educated, had moderate to higher incomes and lived in the capital city, Riyadh. In all, 91% were married, 87% were educated to secondary school level or higher, and 78% had a monthly income of SAR5000 (US$1300) or more. Half of the mothers were employed, working an average of 8 hours per day, and 84% lived in Riyadh. The proportion of babies that were exclusively bottle-fed was 31.5%, with only 15.7% exclusively breast-fed, and 52.8% both breast- and bottle-fed (Table 1).
It was determined that 79.9% of the mothers had one or more maids. Thirty per cent of maids had responsibility only for cleaning the house; 16% only looked after the children; and 53% had responsibility both for cleaning the house and nurturing the children (Table 1). It was found that, although almost 80% of the households employed a maid, only 50% of the mothers had careers.
The results based on the mother–child attachment scale can be seen in Table 2. The table shows the phrases with which participants were asked to agree or disagree, and the mothers’ responses. These results show that 5.7% of the mothers believed that their children did not love them, while 57% said that they cannot bear to be separated from their children for short periods of time. It was found that 20.7% of the mothers have experienced difficulties in raising their children; 22.1% became worried if their children were not with them; and 14% felt annoyed by their children. It can be seen that 70.7% of the mothers were extremely proud of their children, even though only 11.4% believed that their children have great futures. About 12% of the mothers said that their children did not obey them, and 16.1% found their children troublesome.
About 16% of the mothers felt that their children did not meet their expectations. Eleven per cent believed that their children made their lives difficult, 18.2% of the mothers had feelings of anger towards their children and 70.6% (100 – 29.4 = 70.6%) believed that their children were impatient. From these responses it was calculated that the overall level of mother–child bonding is high, in the order of 61.9%.
When questioned about the impact of hiring a maid on their relationship or bonding with their children, 30.4% of mothers agreed that the relationship was negatively affected, and a large proportion (24.2%) declined to answer the question. The remaining 45.2% of mothers claimed that their relationship with their children was not affected by the presence of a maid (Table 3).
Increasing levels of education have enabled women to enter the workforce, which results in less time being available to devote to child-rearing (although the additional income earned by most of these mothers may not be essential for the well-being of the family). Women have the right to an education and subsequently to a career; however, the recruitment of maids appears to have promoted a shift away from traditional Arab family values, which have been regarded as binding households together and leading to the creation of well-balanced individuals with strong family ties and interpersonal relationships.
These strong family ties are perceived to have waned over the last two decades. This could be attributed in part to the hiring of maids, among other factors.
Mothers who choose to breastfeed have higher levels of maternal–fetal attachment.3 The emotional state of the mother during pregnancy, and the level of social support received during that time, are related to the mother's ability to bond with her child both during and after pregnancy.4 Some studies have found that attachment begins in the womb, and women with higher levels of maternal–fetal attachment are more likely to breastfeed than those with lower levels of maternal–fetal attachment.3
In the present study, a very high proportion of babies (31.5%) were entirely bottle-fed. According to Hawwas,5 Islamic law requires breastfeeding for a minimum of 2 years. Only 15.7% of the babies in this study were exclusively breastfed. It was found that about 53% of mothers both breastfed and bottle-fed their babies. If the last two figures are combined, it could be assumed that around 69% of mothers breastfed; however, it is not completely certain that those who both bottle- and breastfeed do not resort to bottle-feeding most of the time. The investigator's impression after questioning mothers was that most babies in the ‘bottle- and breastfed’ group were usually bottle-fed, so that within this group bottle-feeding is the norm. In any event, the low proportion of mothers using breastfeeding alone suggests a very low level of breastfeeding, which does not satisfy the Saudi government's call for levels of breastfeeding to be in the order of > 60%. The results of the present study showed that the absence of the mother tends to affect breastfeeding, which agrees with a recent study that reviewed mothers suffering from asthma who were unable to breastfeed during the course of their treatment.6 Several respondents indicated that short maternal leave prevented breastfeeding.
Interestingly, very few studies worldwide have examined the impact of live-in domestic staff on mother–child attachment. The findings of the present study demonstrate the development of a unique and disconcerting lack of firm mother–child attachment in a select population of households employing maids in Saudi Arabia; this is also relevant to all GCC countries in which the employment of overseas maids is widespread. The results indicate that the level of attachment is lower when a maid is present. Even though the majority of households have maids, only about half the mothers in the study have a career. This indicates that the low attachment between a mother and her child is generally not caused by the absence of the mother due to career commitments, but rather an overdependence on the maid to look after the children even when the mother is at home. Indeed, it is not uncommon to find the baby left almost totally in the care of the maid in households where the mother has no career commitments, a practice which may negatively affect the psyche of the child.
This should not imply that refraining from employing maids will be the correct course of action. Maids undeniably perform a valuable service; however, their presence appears to have the potential to undermine mother–child bonding, with serious potential long-term psychosocial implications for the GCC Arab society. The negative implications for the child could have far-reaching consequences, well beyond poor mother–child bonding. The education of mothers in parenting skills to foster mother–child attachment is recommended, as opposed to abandoning the employment of maids. As well as performing an important role in assisting with household chores, maids contribute significantly to the economy of their own, usually less affluent, countries; in turn, this helps foster strong relationships between the provider and host countries. There are, therefore, positive aspects of hiring domestic staff. However, mothers in GCC countries must be more actively involved in raising their children to ensure their healthy development.
Studies have shown that the strength of a child's attachment to his or her parent is related to anxiety symptoms.7 The importance of the presence of an attachment figure has been found to increase with age,3 through mid-childhood and adolescence. Therefore, the continued presence of an attachment figure is important to the emotional security and development of a child. Employment visas are valid for 2 years in Saudi Arabia and, indeed, all GCC countries provide only limited periods of residence for maids. The visa is extendable; nevertheless, most maids choose to move elsewhere or return to their home countries at the end of the contract. Following the departure of a maid, a replacement is usually engaged. Based on current findings and past, unmeasured, observations, it appears that the child bonds with the maid more strongly than with the mother, and with the departure of the maid at the end of her contract the child is left without this emotional support. With the arrival of another maid, the child must establish a new bond, which is again lost at the end of the replacement maid's contract, and so on. This situation results in a disorganized pattern of attachment during early childhood similar to that seen in challenged mothers8 (e.g. handicapped mothers, those with a poor education, single mothers) and could have serious consequences and implications.9
This lack of attachment could result in a sense of insecurity in the child, and impair his or her normal psychological development; as a consequence, a pathological state of varying degrees of insecurity could manifest in future generations in the GCC countries. The major causes of insecurity in childhood have been described.10,11 These include physical and emotional neglect; physical or emotional abuse; separation from the primary caregiver; changes in the primary caregiver, that is, contact with a succession of maids or staff at day-care centres; frequent moves or placements, especially in orphanages or foster homes; traumatic experiences; maternal depression or withdrawal (caused by a number of factors); and inexperience or a lack of parenting skills on the part of the mother. Poor emotional attachment during childhood may lead to difficulties in forming lasting interpersonal relationships in adult life, which could impair an individual's ability to get on with others. It may also contribute to high divorce rates as affected individuals struggle to form lasting relationships, and could even lead to increased crimes rates. Another possible outcome of a lack of maternal care in childhood is obesity,12,13 and possibly other diseases not yet known to be associated with this problem. In the present study, maternal employment does not appear to be the cause of poor mother–child attachment, but rather an overdependence on maids to look after children.
Another interesting finding concerns the percentage of mothers who chose not to respond to questions about pride, love and anger in relation to their children. This may suggest the mothers either did not know how to respond or were afraid to agree with negative statements about their children. Given the prevailing cultural conditions, it is suspected that these mothers do not wish to acknowledge any negative impact on the mother–child relationship caused by the presence of a maid, and therefore did not answer the question. If this assumption is correct, and the proportion of mothers declining to answer is added to the proportion who agreed that bonding between mother and child was adversely affected, then around half the study population (54.8%) can be said to be affected by impaired mother–child bonding.
In addition, some maids may be very young girls with no experience of working with children. No reliable source of data can be obtained on the ages of maids. Documents prepared by the International Labour Organization and the Philippine Institute of Development Studies suggest that the minimum age of maids is around 18 years;14,15 however, newspaper reports suggest that maids as young as 16 years of age are employed in the United Arab Emirates.16 These maids are not trained childminders, but rather housekeepers in charge of both the upkeep of the home and the care of the children. Leaving babies in the care of untrained workers could have negative long-term consequences.
It is common knowledge that, in some countries, employers may provide childcare facilities within their premises so that mothers can frequently interact with their children. This enhances mother–infant bonding and helps to ensure the healthy development of the infant. It is suggested that employers in the GCC countries and elsewhere should consider providing such childcare facilities to allow regular visits to the children by their mothers. This is supported by the finding that mothers who work part-time appear to raise their children better than mothers who work full-time.17 Government family-friendly work policies, providing longer maternity leave and education on responsible parenting, may be required and could be an important consideration for promoting healthy family lifestyles and early childhood well-being. The GCC employment system should consider allowing working mothers to work part-time or flexible hours while receiving full-time pay (as practised in Australia), allowing them to devote more time to child-rearing to ensure the mental and physical health of future generations. The healthy development of our children begins with the security that they feel in their relationships with their primary caregivers.
To date, no comparable studies have been published on the relationship between the presence of maids and compromised maternal–child attachment in Saudi Arabia, and perhaps throughout the GCC countries. This study has shown a need for more research examining mother–child attachment in Saudi Arabia and elsewhere in the GCC, and for a more in-depth look at the effect that the presence of maids has on family dynamics and on the psychological development and well-being of the affected child, as well as the future ability of that child to form lasting relationships. In addition, a follow-up study should test specific factors that affect the mother–child attachment in the context of the Saudi Arabian and GCC culture and lifestyle.
This study highlights that the attachment between mother and child is affected by the employment of maids for the purpose of child-rearing. This could prove detrimental to the psychosocial development of affected children and the population of the GCC countries in the long term. Family-friendly work policies for mothers and education on responsible parenting are recommended.