Science & Sensibility

In January of 2012, Marian MacDorman and her colleagues compiled a data brief for the United States Department of Health & Human Services, Center for Disease Control and Prevention, National Center for Health Statistics. This brief, entitled Home Births in the United States, 1990- 2009, noted large changes in birthing patterns have occurred in the US over the past century. In 1900, most births occurred at home. By 1940, 44% of all births were at home, and by 1969, this dropped to 1%, and this rate held steady throughout the 1980′s.

The researchers state that homebirths have been increasing since the 1990′s through 2009. In 2004, homebirths accounted for .56% (23,150 births) and increased by 29% to .72% (29,650 births) in 2009. The composite demographic of a woman desiring a homebirth is non-Hispanic Caucasian, over 35 years old, with previous children. The homebirth demographic has a lower risk profile: fewer preterm, low birthweight, multiple births and fewer, teenaged and unmarried mothers. 1 in 90 births to non-Hispanic Caucasian women were homebirths.

Generally, there were more homebirths in rural areas than non-rural areas and more in northwestern states than the southeastern states. Montana, Oregon and Vermont had the highest percentage of homebirths followed by Idaho, Pennsylvania, Washington and Wisconsin. Some of the states with lowest homebirth rates are Texas, North Carolina, Connecticut, District of Columbia, New Jersey and West Virginia.

62% of these home births were attended by midwives: 19% by certified nurse-midwives (CNM) and 43% by other midwives (direct-entry or certified professional midwives).

An Interview with Homebirth Midwife, Angelita Nixon, CNM

Angelita Nixon, CNM, is one of those home birth midwives in West Virginia. I had the pleasure of speaking with Angy about her work last week. Her career parallels the changing trends in US birth care. She began her career in 1998 as a certified nurse-midwife in a hospital. In 2003, she began doing home births exclusively.

Angy says: “ I left the medical arena feeling burned out. My caseload was getting heavier and heavier. A full medical practice were my golden handcuffs. It was impossible to give the personal care I wanted to give to women, I was always rushing. Worse than rushing, I felt like I was witnessing crimes against women. And not only was I witnessing crimes against women, I felt I was a party to this. I saw many crimes against women: mistreatment, being disrespected, taking away personal power, denying a woman the ability to walk, not literally confining a woman, but discouraging her. I saw medical rape often, I did not perform this myself, but saw it happen. A woman would say, “I need to relax for a minute before you examine me” but she was ignored. I couldn’t do that work anymore, I knew there was a better way. You know, at first in my career, I distanced myself from homebirth, I thought those people were extremists. But, I began to have women ask me to attend home births and I liked the people and the work.”

Describing her practice: “I do about 3 births a month. I don’t like missing births and I won’t run the risk of being over-committed. I love it when people pop into my office, which is my home, as they need. I love being able to have long patient visits. Most importantly, I assess the person as a good fit for home birth. My patient population is low risk.”

She describes her work as modeled after the European midwifery: “In Europe, the system is completely different, it’s all midwife based. Doctors are the experts, the midwives are the generalists who deliver 80 – 90 % of births. The midwives listen to the women, to what’s going on in the family, assesses if she has had a traumatic experience in her life which might affect the birth. In this way, the midwives filter out the 10 -15% of the women who will need doctors. That is how I run my practice.”

“We have lost the generation where homebirth was the norm. Our maternity system would look different if its ultimate goal was health and not profit. The funny thing is, intensive midwifery care saves money, as it is less es pensive than traditional hospital care. The Washington Department of Health (2008) found that midwifery care would save Medicaid $500,000 biennially and if private insurance was included, $2.7 million. So sensitive midwifery care is less expensive and has better maternal-baby outcomes. Why do we wait? ”

She uses the following  comfort measures: hydrotherapy, freedom of movement, repositioning, massage, acupressure, efflureage, eating, drinking, hydrating, respectful treatment, continuous support, encouragement,, hot & cold therapies, and a lot of hands on comforting. Her homebirth statistics are impressive: because of careful pre-screening, she has had only one emergency transfer, her cesarean section rate is 7%, and she has done one episiotomy in 8 years.

Ms. Nixon says the system needs reform: “We need more midwives, as they provide the best outcome. I want to collaborate I want to be a medical provider. I do know my limits, I do know when to send a patient to the next level. But I find the hospitals shun this type of collaboration. This is a barrier for the women in my care. I have already triaged the patient, but then the patient is not directly admitted, but must get triaged again in the ER. They say there is a shortage of nurses. I know there is not a nursing shortage, but a shortage of people, nurses, who will work in our hospital’s conditions. Healthcare is in crisis, that’s why there are pressures for reform. We need more midwives, but the system needs reform.”

Ms. Nixon became politically active in order to help change the political climate. She was on the board on the Midwives Alliance of North America (MANA). She is also on the board of the National Midwifery Organization and is President of her state’s chapter. She contributes to MANA’s data collection project. She asks that we spread the word that researchers are needed to interpret the prospective data that has been collected: over 25,000 courses of midwifery care is available for researchers to study. The data is from 2001 – 2011, every client enrolled in the study at beginning of pregnancy, not based on results, voluntary contribution , not restricted to any one type of credential (physicians, hospital based, majority of the data is from homebirth midwives). Qualified researchers can apply for access to the data, by application to the Division of Research of MANA, which is headed by Melissa Cheyney.

Angy ends our conversation with a smile: “Homebirth is the real world. Birth is in its natural habitat. “

References:

Health Management Associates (2008). Midwifery licensure and discpiline program in Washington State:Ecxonomic Costs and Benefits

 

MacDorman, M.F., Mathews, M.S. & Declerq, E. (2012). US Department of Health & Human Services, Center for Disease Control and Prevention, National Center for Health Statistics. NCHS Data Brief # 84, Home births in the United States, 1990- 2009.

Angelita (Angy) Nixon, CNM, MSN

Having practiced full-scope midwifery in hospitals, clinics, and a freestanding birth center, Angy became a midwife business owner in 2003, provides mobile midwifery services and makes house calls. She participates in peer reviews and maintains a formal collaborative agreement with a physician, as well as collaborative relationships with multiple other physicians. In celebration of her first 7 years in private practice, Angy enjoyed a modified sabbatical, traveling and spending more time with her family. In June 2011, she attended her first ICM Congress in Durban, South Africa. Angy believes birth is a normal process and a healthy event.

Find her at her website.

Kathy Morelli Babies, Baby Friendly Initiative, Childbirth Education, Healthy Birth Practices, Home Birth, Lamaze Method, Midwifery, Uncategorized Kathy Morelli, lived experience of midwifery clients, Midwifery Care, midwives

A guest posting by Jill Wodnick, MA

Hudson Perinatal Community Doula Valerie Inzinna explains,

“I first met Tina (not her real name) in January. She was nervous, scared and very much alone. We took Lamaze childbirth education classes together at a federally funded health center; we toured her birthing hospital and discussed everything from car seats and slings to timing contractions. My back-up doula Alison Chiappetta and I were impressed from the beginning with Tina’s inner strength, her intelligence and her commitment to breastfeeding her expectant baby, Rose.   Our doula  time together was more than just educational; it was emotionally intimate.  As Tina shared her very real fears and concerns with us, she became more confident in her abilities to not only birth, but parent. At our last meeting together before she gave birth, for the very first time Tina said, ‘I can do this,’ as she caressed her belly with her hands. We agreed!”

The state of New Jersey is an interesting and complex microcosm of birth and breastfeeding for American women. Some counties are extraordinarily wealthy, while others have some of the highest poverty rates in the nation. From the highest cesarean birth rates (44%-51% c-section rates in Hudson County hospitals) to growing homebirth rates, but with no free-standing birth centers, the state with the highest density of people presents many challenges to the Lamaze evidence based care practices for birth and breastfeeding. Tina’s story dramatizes the tremendous power of the community doula model as well as the tremendous difficulties of implementing it effectively.

Tina is a 20 year old woman enrolled in a local community college and living in Jersey City. Her prenatal medical care was supported through a Medicaid managed plan at an FQHC (federally qualified health center); WIC services; and community doula care and childbirth education delivered through HPC (Hudson Perinatal Consortium). This alphabet soup of public health programs would be much more difficult for expectant moms like Tina to navigate without what HPC Community Doulas do: engage, inspire and support their clients.

Founded in the summer of 2010 through an Access to Prenatal Care grant from the New Jersey Department of Health & Senior Services, the Hudson Perinatal Consortium’s Community Doula Program offers relationship-based intervention to low-income expectant women. Our clients, who receive free doula care with home visits and breastfeeding support, are enrolled in Medicaid, in WIC, or are without insurance. Our comprehensive doula training and education is free for women wanting to be doulas through Merck’s NJ Neighbor of Choice Award. Our doulas get cross trained in many public health topics, among which are the Lamaze Care Practices for a Safe & Healthy Birth. With a 20 hour a week commitment for training, the women entering our fellowship see first-hand how poverty impacts pregnancy and parenting.

HPC Doula Mary Szubiak summarized research on doula care as part of her training with us.  In her summary, she states that “doulas offer value as they work toward providing more positive obstetric outcomes in an attempt to reduce birth disparity among women. Research has shown that black non-Hispanic mothers experience much higher rates of preterm labor, low birth weight, and fetal and maternal mortality (Martin et al. 2006). By providing doula services, we work with many other community health partners to reduce this disparity.  A national survey highlighted that the women with the least amount of resources are most likely to benefit from doula care and are least likely to receive it (Lantz, et al., 2005). Furthermore, a focused study in Northern California involving low-income participants concluded that doula care was associated with timely onset of lactogenesis and higher breastfeeding prevalence at 6 weeks postpartum (Nommsen-Rivers et al 2009).”

Just a few days ago, Tina gave birth to Rose, who looks exactly like her mother. It was a natural birth with directed pushing in the supine position after which the baby was routinely separated but then returned to breastfeed.

Unfortunately, some of the most important care practices for safe and healthy birth, like freedom of movement, and non-separation of mother and baby, are not supported by the system mothers like Tina typically birth in.

HPC Doula Alison explained, “When Valerie and I left Tina and baby Rose, we were thrilled to know that she was committed to exclusive breastfeeding. After her discharge from the hospital, I checked in with Tina by phone to see how things were going. As she was settling into her new role as Rose’s mother, she informed me that Rose had been given formula at the hospital on the day following her birth since Tina was told by the nurse that she ‘did not have any milk in her breasts and Rose was nursing constantly because she was hungry.’ Since they have returned home, Tina has not had success inviting Rose to latch on her breast and has resorted to pumping and offering expressed breastmilk in a bottle. I am amazed at Tina’s commitment to feeding her daughter breastmilk, but am also saddened by the misinformation received at the hospital which has had a huge impact on her ability to breastfeed naturally.  I found it so frustrating that all the information Tina had heard and digested during her pregnancy had been undermined by what she was told during her hospital stay and it seems that it has had a profound impact on her breastfeeding relationship.”

My role as the HPC Community Doula Fellowship Coordinator blends my passion for social justice beginning with birth and breastfeeding with the clarity that the safe and healthy birth practices I teach are evidence-based thanks to Lamaze International.  I encourage all Lamaze International members to learn about community health programs.  Nationally, 44% of pregnant women birth through Medicaid.  By making an impact in public health programs like Medicaid through the research and resources of Lamaze, we can truly change the culture of birth and breastfeeding for all families.

_____________________________________________

Jill Wodnick, M.A., is a Lamaze & Birthing From Within trained childbirth educator; an advanced doula trainer; a prenatal yoga instructor and a mom of 3 boys.  She runs the Hudson Perinatal Consortium’s CommunityDoulaFellowship.  Please visit www.HPCDoulas.com or www.Hudsonperinatal.org

Lantz PM, Kane Low L; Varkey S, Watson R. L. (2005). Doulas as childbirth paraprofessionals: Results from a National Survey. Women’s Health Issues. 2005: 15: 109-116.

Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, and Kirmeyer S. (2006). Births final data for 2004. National Vital Statistics Reports 55(1). Hyattsville, MD: National Center for Health Statistics.www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_07.pdf

Mastergeorge AM, Hansen RL, Cullum AS, Dewey KG. (2009). Doula care, early breastfeeding outcomes, and breastfeeding status at 6 weeks postpartum among low-income primiparae. Journal of Obstetrics Gynecology Neonatal Nursing. Mar-Apr;38(2):157-73.

Nommsen-Rivers LA, Mastergeorge AM, Hansen RL, Cullum AS, Dewey KG. (2009). Doula care, early breastfeeding outcomes, and breastfeeding status at 6 weeks postpartum among low-income primiparae. Obstetrics Gynecology Neonatal Nursing. 2009 Mar-Apr;38(2):157-73.

Kathy Morelli Babies, Baby Friendly Initiative, Childbirth Education, Doula Care, Guest Posts, Healthy Birth Practices Childbirth Education, Healthy Birth Practices, Kathy Morelli, lamaze, no separation

On Monday, February 27, 2012, the American Academy of Pediatrics (AAP) published its revised policy statement, Breastfeeding and the Use of Human Milk.  Since presenting the best, evidence based information to our students, clients and patients is paramount, we suggest you read the publication thoroughly.  In this article I will highlight some of the key things to note.

“The AAP reaffirms its recommendation of exclusive breastfeeding for about 6 months, allowed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant.”

This is current to what we’ve been teaching.  However the note at the end about “as mutually desired by the mother and infant” is encouraging with regards to the WHO’s recommendations: “Exclusive breastfeeding is recommended up to 6 months of age, with continued breastfeeding along with appropriate complementary foods up to two years of age or beyond.”   So, the AAP doesn’t go as far with regards to extended breastfeeding as does the WHO, but they acknowledge that there are benefits to breastfeeding longer than one year.

Breastfeeding rates over all have increased slightly over the last decade, but we still have a huge disparity with regards to the age of the mother, as well as the racial and socio-economic background of the mother.  Strikingly:

“Furthermore, 24% of maternity services provide supplements of commercial infant formula as a general practice in the first 48 hours after birth. These observations have led to the conclusion that the disparities in breastfeeding rates are also associated with variations in hospital routines, independent of the populations served. As such, it is clear that greater emphasis needs to be placed on improving and standardizing hospital based practices to realize the newer 2020 targets.”

That said, it would appear that we need to encourage our hospitals to become Baby Friendly.  In the policy statement, they give us the statistics on the lack of Baby Friendly compliance in the U.S.  The AAP encourages hospitals to practice the 10 Steps and says “the rate of exclusive breastfeeding during the hospital stay has been confirmed as a critical variable when measuring the quality of care provided by a medical facility.”

The publication addresses a wide range of illnesses ameliorated by breastfeeding.  It is noted whether the percent lower risk was with regards to any breastfeeding, or by number of months of breastfeeding.  Unsurprisingly, a fair number of conditions had reduced risk the longer the mother breastfed.  Please refer back to the policy statement for details.

SIDS: 

“…note that breastfeeding is associated with a 36% reduced risk of SIDS.” 

Pacifier Use: 

“Given the documentation that early use of pacifiers may be associated with less successful breastfeeding, pacifier use in the neonatal period should be limited to specific medical situations. These include uses for pain relief, as a calming agent, or as part of structured program for enhancing oral motor function. Because pacifier use has been associated with a reduction in SIDS incidence, mothers of healthy term infants should be instructed to use pacifiers at infant nap or sleep time after breastfeeding is well established, at approximately 3 to 4 weeks of age.”

Is your baby smarter because you breastfed her? The short answer is yes for infants exclusively breastfed for 3 months or longer as well as for preterm infants, however:

“Consistent differences in neurodevelopmental outcome between breastfed and   commercial infant formula–fed infants have been reported, but the outcomes are confounded by differences in parental education, intelligence, home environment, and socioeconomic status.”

Guidelines for premature infants include:

“The potent benefits of human milk are such that all preterm infants should receive human milk. Mother’s own milk, fresh or frozen, should be the primary diet, and it should be fortified appropriately for the infant born weighing less than 1.5 kg. If mother’s own milk is unavailable despite significant lactation support, pasteurized donor milk should be used.”

Maternal outcomes are also discussed – everything from breastfeeding aiding the involoution of the uterus after birth, to reduced rates of many diseases, including breast cancer and ovarian cancer:

“Cumulative duration of breastfeeding of longer than 12 months is associated with a 28% decrease in breast cancer (OR: 0.72; 95% CI: 0.65–0.8) and ovarian cancer (OR: 0.72; 95% CI: 0.54–0.97). Each year of breastfeeding has been calculated to result in a 4.3% reduction in breast cancer.”

With regards to vitamin and mineral supplements, the AAP recommends the Vit. K shot over the oral version because “the oral dose is variably absorbed and does not provide adequate concentrations or stores for the breastfed infant”.  They do, however, recommend delaying the shot until after the baby’s first breastfeeding.

Vit. D supplements are suggested for all breastfed infants upon release home because:

“Vitamin D deficiency/insufficiency and rickets has increased in all infants as a result of decreased sunlight exposure secondary to changes in lifestyle, dress habits, and use of topical sunscreen preparations.” 

Supplementary fluoride is not recommended under 6 months of age.

There are many other good data points of note in this policy statement, including information on the economic benefits of breastfeeding, contraindications to breastfeeding, charting normal infant growth and specific data points on individual diseases, etc.

I’ll leave you with this concluding statement:

“Pediatricians also should serve as breastfeeding advocates and educators and not solely delegate this role to staff or nonmedical/lay volunteers. Communicating with families that breastfeeding is a medical priority that is enthusiastically recommended by their personal pediatrician will build support for mothers in the early weeks postpartum.”

…..

“Thus, infant feeding should not be considered as a lifestyle choice but rather as a basic health issue.”

How do we as educators and birth professionals address this?  We support evidence-based practices, yet at the same time we say we support a parent’s right to make an informed choice.  How will you incorporate what you’ve read here, and in the AAP’s policy statement, into your classes?

Deena Blumenfeld Baby Friendly Initiative, Breastfeeding, Childbirth Education, Evidence Based Medicine, Guest Posts, Practice Guidelines American Academy of Pediatrics, Baby Friendly Hospital Initiative, breastfeeding, Healthy Birth Practices, Pediatricians

Mother and Child Reunion

The goal of Lamaze “Healthy Birth Practice #6, Keeping Mother and Baby Together – It’s Best for Mother, Baby, and Breastfeeding” is to encourage and support mothers so they may confidently insist that they not be separated from their newborns, and be allowed to have ample opportunity for skin-to-skin contact without delay or interruption, as recommended by a multitude of sources concerned with infant and maternal health.

Dr. Lennart Righard’s seminal study¹, published in the Lancet in 1990, gave rise to his famous video, “Delivery Self Attachment”², which illustrated parts of that research.  It shows babies who, when left undisturbed on their mothers’ bodies immediately after birth, find the breast by themselves, crawl to it and suckle with competence. It observes also those babies whose abilities are either impaired or negated because of exposure to intrapartum meds, separation from their mothers after birth, or both.

“Newborns have a great need for love which makes a separation between mother and child most unfortunate”³, Lennart is quoted as saying, poignantly, in a blurb on the packaging of his video. A banner below that quote, set in 16-point type and caps, proclaims “THIS SIX MINUTE VIDEO WILL CHANGE PROTOCOLS!”

It is ”unfortunate” indeed that  many mothers still experience resistance to this best-evidence protocol; hospital staff and caregivers still whisk newborns away for routine procedures, processing and observation after just a few minutes of time with their mothers.   As with so many maternity-care practices, the protocols that Righard thought with certainty would change, are still in place, even as the evidence for keeping mother and baby together mounts.  Some state Departments of Health, as that in Ohio, have got it right, and officially recommend skin-to-skin. That state prints and distributes cards for its WIC program that read, in part:  “Hold me, Mom. Babies who are held skin-to-skin on their mother‘s chest right after birth are happier and less likely to cry, are more likely to latch on and [sic] breastfeeding well, have better heart rates, have better temperatures than under a warmer, have better blood sugars, burn less [sic]  calories than under a warmer. So, be sure to tell your doctor and the hospital nurses that you want to hold your baby for at least the first hour after the birth, skin-to-skin (baby naked, not wrapped in a blanket). That‘s the best way to introduce your baby to the world”⁴. (Emphasis mine.) How can we account for the fact that a mother is advised by a government agency to “be sure” to tell her doc and staff to give her best-evidence care? Even for this well-documented and uncomplicated course of action, we cannot count on our caregivers to act reliably in the interests of mother and baby.  Again, a Healthy Birth Practice can be read as a subtle warning: Do not let them take your baby from you for the first hour!

Mothers have always needed to keep their babies with them, and supporting evidence for that urgent desire has been around for quite a while.  In 1979, Michel Odent proposed, in a theory and review article on human ecology, and under the aegis of his Primal Research Center, that the natural ecology  for an infant is to be skin-to-skin (S2S) with the mother. The Human Ecolog deals with “primal” health, a branch of epidemiology that brings together studies exploring correlations between what happens during the primal period (fetal life, perinatal period and the year following birth) and what occurs later in life in terms of health and personality traits. The treatment of mother and newborn as an inseparable dyad is the basis for those studies and can be found compiled in the Primal Health Research Data base ^5.

With the understanding of what is best for the “primal” health of the newborn, and in light of the wisdom of Healthy Birth Practice #6, the Baby Friendly Hospital Initiative of the WHO and UNICEF very specifically and unequivocally advises that mothers and infants remain together 24 hours a day.  As of May 2011, out of 3,000 or so hospital maternity centers and free standing birth centers in this country, only 110 have achieved the status of Baby Friendly.  No wonder women must be advised and exhorted to ask or demand treatment that should be just pro forma in every LDR. Why must women spend precious energy and focus during labor to advocate for best-evidence care for themselves when that kind of care should just be expectations met?  Period.

Kangaroo Care, “a universally and biologically sound method of care for all newborns,” ⁶ incorporating S2S, breastfeeding and support of mother and baby, has become a standard of care in many NICUs.  While there is no citation to back up that statistic, Wikipedia represents that fully 82% of NICUs in the US practice KC.  That is not surprising, given the wealth of studies going all the way back to 1979 that show how effectively KC helps at-risk babies i.e., improving and normalizing vital signs, stabilizing breathing and heart rate and normalizing glucose and stress levels. Many studies can be accessed at the kangaroo care website: http://www.kangaroomothercare.com.   Kangaroo Care babies have been shown to have significantly higher scores in visual and auditory  orientation, alertness, cuddliness, self-quieting, attention and state regulation, and higher scores at 6 months on the Infant Temperament Questionnaire than standard-care infants.  Kangaroo care has been shown to promote neonatal behavioral organization and enhanced developmental outcomes through the first year of life. ⁷Is it such a stretch to extrapolate that practice to all term healthy newborns whose need for their mothers is just as acute as that of those in NICUs?

There are some fascinating studies about interactions between mother and baby immediately after birth that investigate “the  ‘smellscape’ of mother’s breast: the effects of odor on neonatal arousal, oral and visual responses”.⁸ Here are just a couple of  observations from a multitude of studies available: “volatile compounds originating in areolar secretions or milk, release mouthing, stimulate eye-opening and delay and reduce crying in newborns”.⁹ “The odor of human milk is more attractive to human newborns than formula milk…independent of postnatal feeding experience.”¹⁰

The skin-to-skin interactions between mother and babe are maturational for newborn; the contact stimulates the vagal nerve, causing increased growth in size of the villi in the newborn gut, which provides a larger surface area for the absorption of nutrition. Nancy Mohrbacher, author and breastfeeding expert, in her article “Rethinking Swaddling” ¹¹ has pointed out the differences between the infant held skin-to-skin and those who were wrapped and held by their mothers.  She cites studies showing that swaddling delays the first breastfeed and leads to less effective suckling, greater weight loss, and more jaundice. Routine swaddling has negative effects on the infant whether in the hospital or at home.

In the main, Healthy Birth Practice #6 addresses a mother’s time in the hospital, to promote behavior that is really just a prelude to how mother and baby should proceed together when they go home. But along with that vital and valuable information, another aspect of a new mother’s experience needs to be examined and promoted… we must begin to examine with mothers something that is rarely mentioned, rarely talked about by OBs, and rarely discussed as part of the normal and natural part of a new life coming into the world…the remarkable abilities and competence of the newborn.  Birthing of the placenta gets more coverage in birth literature than do the stellar capacities of a new baby.

The Righard video of newborn behavior amazes because we see the antithesis of what first-time mothers imagine that their infants will be like.  Popular images show a greasy-eyed newborn, wrapped up and be-blanketed as tight as a little taco, handed over to mom to hold. The Righard video, familiar to many of us, causes gasps at the first images of that lively newborn pushing its little legs against its mother’s abdomen, bobbing its little head with power and purpose, and performing the initial latch with brio.  Mothers need to be told that, even if they have had intrapartum medications, they must continually give their newborns the opportunity to perform as they are hard-wired to do, and we must emphasize that newborns are capable and competent. Dr. Christina Smillie’s approach to breastfeeding…and her video “Baby-Led Breastfeeding” ¹² rely on the baby’s instinctive responses to seek and find the breast when they are allowed to stay on their mother’s bodies.  It demonstrates without equivocation how well babies can navigate about to find the breast. Every mother-to-be should be told about the amazing capabilities of her newborn, and encouraged to spend time every day with her newborn skin-to-skin.  That information should be part of every childbirth education syllabus.

A couple of videos that came out this year also address that important hour or so after birth, and illustrate the nine stages through which the newborn progresses.  Sponsored by the Healthy Children Project, the video called The Magical Hour¹³ and based on the research of Anne-Marie Widstrom and colleagues, is aimed at parents-to-be, and shows newborns in all the stages of adaptation to life outside from Stage One, the Birth Cry, to Stage Nine, Sleep. The other video, Skin to Skin in the First Hour after Birth: Practical Advice for Staff after Vaginal and Cesarean Birth ¹⁴, also from the Healthy Children Project, is aimed at hospital staff, delineating the same nine stages as The Magical Hour. It lays out guidelines for the treatment of mother and baby immediately after birth, whether vaginal or cesarean, with the view that the implementation of direct and uninterrupted contact between mother and newborn is the perfect beginning for a new family.

 

 

References

1-      Lancet, Vol. 336,1105-07

2-      Delivery Self Attachment, 1995 Lennart Righard & Kittie Franz, Geddes Productions, Los Angeles, CA

3-      Ibid

4-       Ohio Department of Health. (2008). Hold me, Mom. Columbus, Oh: Ohio Dept.  of Health Printing, Warehouse # 3977.23.

5- www.primalhealthresearch.com Odent, M. (2006).  Homo Super-predator to Homo Ecologicus. http://www.wombecology.com/homo.html#top.

6-www.kangaroomothercare.com/whatis01/htm

7-Fukida M, Moriuchi, Akiyama T, Nugent JK, Brazelton, TB, Arisawa K, Takahashi T, & Saito H (2002) The effects of kangaroo care on neonatal neurobehavioral organization, infant development and temperament in healthy infants through one year. J Perinatology, 22(5).384-379

8-Doucet S, Soussignan R, Sagot P, Schaal B, Dev Psychobiol 49(2); 129-38, 2007 Equipe d’Ethologie et de Psycholbiologie Sensorielle Centre des Sciences du Gout Umr 5170 CNRS Dijon, France. doucet@cesg.cnrs.fr

9-Ibid

10-Mizuno K, Mizuno N, Shinohara T, et al; Mother-infant Skin-to-skin contact after delivery results in early recognition of own mother’s milk odour. Acta Paediatrica 93(12):1640-1645, 2004 katsuorobi@aol.com

11-Rethinking Swaddling, International Journal of Childbirth Education, 2010

12-Baby-Led Breastfeeding, Geddes Productions, Los Angeles, CA, 2007, Christina M Smillie, Ivy Makelin, Kittie    Franz

13-The Magical Hour; Holding Your Baby for the First Hour After Birth. DVD Produced by Kajsa Brimdyr, Kristin Svensson and Ann-Marie Widstrom, www.healthychildren.cc

14-Skin to skin in the First Hour After Birth: Practical Advice for Staff after Vaginal         and Cesarean Birth,  DVD Produced by  Kajsa Brimdyr, Kristin Svensson and Ann-Marie Widstrom, www.healthychildren.cc

Jackie Levine Baby Friendly Initiative, Breastfeeding, Evidence Based Medicine, Films about Pregnancy, Healthy Birth Practices, Healthy Care Practices, Patient Advocacy, Practice Guidelines, Uncategorized delivery self attachment, Healthy Birth Practice #6, Healthy Children Project, Jackie Levine, kangaroo care, Kangaroo Care in NICUs, Kangaroo Mother Care, Keeping Mother and Baby Together, Lennart Righard, Michel Odent, Mother and Child Reunion, no separation of mom and baby, Primal Research Center, skin-to-skin care, skin-to-skin contact

Where We’re At

Country				Initiation %			Exclusivity % at 6 months
Canada				90[1]			14[2]
Australia				92			14[3]
New Zealand				88[4]			26[5]
United States				75			13[6]
Austria				96			46
Germany, Switzerland:				94			11
United Kingdom overall				69			21[7]
Lithuania				98			14
Norway				99[8]			17*[9]
Ireland				47[10]			10*[11]
										*denotes any breastfeeding

There is much to celebrate in the breastfeeding world in regard to the world-wide increase in initiation rates (let’s ignore Ireland’s abysmal 47%).  Alas, such numbers plummet as we speak about duration rates.  Canada’s disappointing record of 17% of babies exclusive breastfeeding at 6 months[12] is matched in many European countries, and USA and others are lower still.  This is both strange and concerning in light of the World Health Organization’s call for exclusivity to around 6 months.  Do we not have enough marketing out there to demonstrate the importance of breastfeeding and the risks of not breastfeeding?  Is it that mothers are not trying hard enough to make it work?

In fact, we have done a great job with our marketing—the initiation rates prove that.  And many countries around the world have made great advances in ensuring babies have the right to breastfeed anywhere.  Like childbirth, the reclaiming of breastfeeding as a woman’s right has been a slow one but it has made concrete and substantial progress.  There is still a significantly long road ahead, to be sure, and we will get there—of that I am confident. 

The Issue of Support
This brings us to my second point, so let’s get the record straight: mothers are trying hard enough—some (like patients in the clinic where I work) are visiting up to 9 practitioners just to get the breastfeeding help they need.  The challenge is, though we encourage mothers to breastfeed, we don’t always make it easy for them to do so:  Birthing has become medicated all too frequently and studies are starting to reveal the adverse effects of this highly medicalized birthing model on the process of breastfeeding.[13],[14]  Despite improving federal policies, on a micro level we still tend to make our public environments non-breastfeeding friendly by admonishing mothers when they breastfeed in places like airplanes, museums, swimming pools and restaurants, and we provide them with very little support on the how-to part of this natural-process-but-learned behaviour. 

It is on this last point that I will focus these next few blog posts:  the support, or lack of good support we give mothers who choose to breastfeed.  This “support” comes in many forms, too many to delve into in this article and many that will eventually work themselves out as the marketing of breastfeeding continues to snowball and win over the nay-sayers and the practitioners who claim: “hey, I wasn’t breastfed and look at me, I’m just fine” (see James Akre’s The Problem with Breastfeeding[15]—it’s an easy read which elegantly addresses this point).  The kind of support I am most concerned about is that which is given in the guise of expert advice or care and yet is anything but.  This support usually comes from nurses and lactation consultants and often from midwives and doctors.  It comes from a lack of solid education in breastfeeding and lactation medicine.   That so many practitioners put so little importance on breastfeeding is a significant part of the issue, to be sure (though obviously this cannot be said of all midwives, doctors, and lactation consultants).  And even more, though they might believe in the importance of breastfeeding, many practitioners don’t have faith in breastfeeding as a way to sustain life and help perpetuate the species. The fact that we are almost 7 billion strong demonstrates breastfeeding must be somewhat responsible in perpetuating our species–remember, commercially–prepared artificial baby milks have only been around for a relatively short while.  In fact, up until very recently, few babies ever received any breastmilk substitutes, therefore it is safe to say that statistically speaking, almost every human being that has ever walked this earth was breastfed. 

So back to the issue of support.  Let me extend kudos to the practitioners who do make it their responsibility to stay updated with their skills and who are never afraid to say, “I don’t know how to fix this, let’s refer you to someone who may.”  The problem, however, lies in the numerous practitioners lacking proper training and education—or those underutilizing the training they do have—and instead rely upon tools and gadgets to augment their breastfeeding support. Unfortunately, nothing can replace good hands-off/hands-on training and mothers far and wide are suffering from practitioners’ ill-equipped attempts to mimic this type of support.   Over the next few months I will share with you my thoughts around how and where we fail when it comes to getting mothers and babies off to the best start.

Support Pitfall #1 ~ Lack of Skin to Skin Contact:  Early Separation/ Rooming in/Swaddling:
Rooming-in has become the norm in Canada for the most part, (thanks largely to The Baby Friendly Hospital Initiative—BFI[16], [17]) though all too often babies are removed from their mothers at night “to give their mothers some rest.” In fact, an alarming but well-intentioned, non-evidenced based new programme is now in place in Toronto, Canada that separates mothers and babies for 5 nights where there is a concern or suspected risk of postpartum depression. All this in the face of tremendous research with overwhelming and compelling evidence that goes against such practices[18],[19],[20],[21],[22],[23]. 

In fact, immediately after birth, babies do best when placed skin-to-skin (SSC—skin-to-skin care/contact[24]) with their mothers for many hours throughout the day not just during feedings but in between feedings as well[25].   Yet in most hospitals in the US, babies are kept either separated from their mothers or are kept swaddled in blankets.  In Canada, though most hospitals have made great strides toward SSC, many nurses still teach mothers how to wrap and swaddle babies in 2 or even 3 blankets to ensure baby stays warm instead of spending time teaching about the benefits of SSC (even though the evidence on SSC clearly shows that babies stay warmer when SSC with their mothers[26]).  With breastfeeding, we want to ensure baby and mother achieve the best latch possible (more on that in the next blog).  Imagine how challenging it is to latch a crying bundle with all those blankets in the way! When babies are kept SSC their SCRIP scores (stability of the cardiorespiratory system in premature infants³⁶)are stabilized.  Likewise, most mothers do better when their babies are with them; they witness less crying in their babies and breastfeeding gets off to the best start[27],[28],[29],[30] , [31],[32],[33].  As importantly, when baby is SSC with mother, the baby will behave in a way which is neurologically appropriate for a newborn—waking when appropriate and cueing when hungry[34].  The baby who is wrapped or swaddled tends not to cue early, and, it is suggested, is more likely to sleep through his/her hunger, “content to starve,” as the old paediatric adage goes.  Or, they sleep so long and then when woken, are so desperately hungry they cry inconsolably and often refuse to eat.  Conversely, SSC ensures timely waking and feeding. There are many recommendations for baby-led feeding and certainly SSC makes it increasingly possible. 

Paediatrician and public health specialist, Dr. Nils Bergman speaks about placing baby in the correct habitat[35] so that s/he can behave in a way which is neurologically appropriate[36].  Dr. Bergman suggests that when babies are wrapped or swaddled their behaviour changes and becomes conservationist (of their energy—they shut down, and seem to sleep but really are doing nothing of the sort) or becomes desperate (they utter distress cries)[37].  Furthermore, when a baby is placed skin to skin with his mother he will find the way to the breast on his own and begin the “breastfeeding process” (exchange of necessary sensory information[38]) well before actual sucking begins.  This journey and subsequent sucking at the breast is critically important for baby’s neurological organization and survival.

A baby will behave like a baby when in the habitat of her parent’s body, especially her mother’s.  Wrapping or swaddling babies is an unfounded practice that needs to go and this applies to babies whose mothers do intend to breastfeed and even more so for those who don’t.  If we want babies and babies’ brains[39] to have a healthy start it is crucial we help them get to the starting line.  And as for establishing breastfeeding?  Skin to skin!  Provide the vehicle, and they will know the way.  

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[1]Breastfeeding Initiation in Canada: Key statistics and graphics 2007-2008 www.hc-sc.gc.ca

[2]Chalmers B et al. Breastfeeding rates and hospital breastfeeding practices in Canada: A national survey of women. Birth 2009, June;36(2)122-132

[3] Australian National Breastfeeding Strategy. 2009, Commonwealth of Australia on behalf of the Australian Health Ministers Conference (2009)

[4] Breastfeeding and Weaning Practices in New Zealand: Breastfeeding and Prenatal Nutrition Issues.  Nutrition Research Newsletter. Aug 2002

[5] New Zealand Ministry of Health (2007) www.moh.govt.nx/moh.nst/index.mh/heha-nations-breastfeeding-campaign

[6]Centres for Disease Control and Prevention. www.cdc.gov/breastfeeding/data/NIS_data/index.htm

[7]Yngve & Sjostrom. Breastfeeding in countries of the EU and EFTA: Current and proposed recommendations, rationale, prevalence, duration and trends. Public Health Nutrition 4(2B)631-645

[8]Cattaneo et al. Protection, promotion and support of breastfeeding in Europe: Current situation. Public Health Nutrition 2005 8:39-46

[9] www.breastfeeding.ie/policy-strategy (2008)

[10]Tarrant & Kearney. Session 1:Public health nutrition. Breast-feeding practices in Ireland. Proc Nutr Soc 2008 Nov;67(4) 371-80

[11] www.breastfeeding.ie/policy-strategy (2008)

[12] It is important to note that many countries are still suggesting solid foods be introduced at 4 or 4-6 months and so this column might be somewhat skewed.  Often the number will refer to any breastfeeding.  Stats on true exclusivity are difficult to obtain.  The stats do show, however, that even at 3 months, there is not much difference between 3 and 6 months when referring to exclusivity.  

[13]Kroeger M & Smith LJ Impact of Birthing Practices on Breastfeeding: Restoring the Mother-Baby Continuum Boston, MA: Jones & Bartlett Publishers, 2004

[14]Ransjo-Arvidson, AB Matthiesen AS, Lilja G, Nissen E, Widstrom AM, Uvnas-Moberg K. Maternal analgesia during labour disturbs newborn behaviour: effects on breastfeeding, temperature, and crying.  Birth.  2001; 28 (1): 5-12

[15]Akre, James, The Problem With Breastfeeding:  a Personal Reflection,  Hale Publishing, 2006

[16] The Baby Friendly Initiative’s Ten Steps help to ensure rooming in is secure.  However, so few North American hospitals have earned this accreditation.

[17] Pincombe J, Baghurst P, Antoniou G, Peat B, Henderson A, Reddin E. Baby Friendly Hospital Initiative practices and breast feeding duration in a cohort of first-time mothers in Adelaide, Australia Midwifery. 2006

[18]Buranasin B. The effects of rooming-in on the success of breastfeeding and the decline in abandonment of children. Asia Pac J Public Health. 1991;5(3): 217-20.

[19]Song JE. A comparative study on the level of postpartum women’s fatigue between rooming-in and non rooming-in groups. Korean J Women Health Nurs. 2001;7:241–255.

[20]Kim ES, Park YS. The effect of rooming-in on maternal attitude and self confidence for infant care among primiparas. Korean J Women Health Nurs. 2001;7:256–270.

[21]Song JE, Lee MK, Chang SB. Differences of maternal fetal attachment between the rooming-in and non-rooming in groups of postpartum women. J Korean Acad Nurs. 2002;32:529–538.

[22]Kjellmer I, Windberg J. The neurobiology of infant-parent interaction in the newborn: an introduction. Acta Paediatr Suppl 1994; 397:1-2.

[23]Hofer MA. Early relationships as regulators of infant physiology and behaviour.  Acta Paediatr 1994; Suppl 397: 9-18.

[24]This kind of care is based on KMC (Kangaroo Mother Care) started in Bogotá, Columbia by Dr. Rey and Dr. Martinez, 1979

[25]Bystrova K, Matthiesen AS, Widstrom AM, Ransjo-Arvidson AB, Welles-Nystrom B, Vorontsov I, Uvnas-Moberg K.  The effect of Russian Maternity Home routines on breastfeeding and neonatal weight loss with special reference to swaddling.  Early Human Develop. 2007; 83:29-39

[26]Anderson GC, Moore E, Hepworth J, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2003;(2):CD003519

[27] Nissen E, Lilja G, Widstrom AM, Uvnas-Moberg K. Elevation of oxytocin levels early post partum in women.  Acta Obstet Gynecol Scand. 1995; 74(7): 530-3.

[28] Boutet C, Vercueil L, Schelstraete C, Buffin A, Legros JJ. Oxytocin and maternal stress during the post-partum period.  Ann Endocrinal (Paris). 2006; 67(3): 214-23

[29]Christensson K, Siles C, Moreno L, Belaustequi A, De La Fuente P, Lagercrantz H, Puyol P, Winberg J. Temperature, metabolic adaptation and crying in healthy full-term newborns cared for skin-to-skin or in a cot.  Acta Paediatr. 1992; 81: 488-493.

[30]Michelsson K, Christensson K, Rothganger H, Winberg J. Crying in separated and non-separated newborns: sound spectrographic analysis.  Acta Pediatr 1996; 85(4): 471-5

[31] Rapley G. Keeping mothers and babies together–breastfeeding and bonding.  RCM  Midwives. 2002 Oct; 5(10): 332-4

[32] Vaidya K, Sharma A, Dhungel S. Effect of early mother-baby close contact over the duration of exclusive breastfeeding.  Nepal Med Coll J. 2005;7(2):138-40

[33] Rapley G. Keeping mothers and babies together–breastfeeding and bonding.  RCM  Midwives. 2002 Oct; 5(10): 332-4

[34]Hofer MA. Early relationships as regulators of infant physiology and behaviour.  Acta Paediatr 1994; Suppl 397: 9-18.

[35]Bergman NJ, Linley LL, Fawcus SR. Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200- to 2199-gram   newborns.  Acta Pediatr 2004; 93 (6): 779-85.

[36]Ferber SG, Makhoul IR. The effect of Skin-to-Skin Contact (Kangaroo Care) Shortly After Birth on the Neurobehavioural Responses of the Term Newborn: A Randomized, Controlled      Trial.  Pediatrics 2007; 113: 858-865

[37]Bergman NJ, Jurisoo LA. The ‘kangaroo-method’ for treating low birth weight babies in a developing country.  Trop Doct 1994; 24(2): 57-60.

[38]McKenna JJ, Thoman EB, Anders TF, Sadeh A, Schechtman VL, Glotzbach SF.  Infant-parent co-sleeping in an evolutionary perspective: implications for understanding infant sleep development and the sudden infant death syndrome.  Sleep 1993; 16(3): 263-82.

[39]Schore AN. Effects of a secure attachment relationship on right brain development affect regulation, and infant mental health.  Infant Mental Health Journal 2001; 22(1-2): 7-66

Posted by:  Edith Kernerman, IBCLC, NBCI

Edith Kernerman Baby Friendly Initiative, Breastfeeding, Science & Sensibility breastfeeding statistics, breastfeeding support, breatfeeding gadgets, Edith Kernerman, Harvey Karp, how to breastfeeding, International Breastfeeding Centre, Jack Newman, James Akre, kangaroo care, latch-on, MD, Newman Breastfeeding Institue & Clinic, Nils Bergman, problems with breastfeeding, skin-to-skin contact, swaddling, The Problem with Breastfeeding