Science & Sensibility

A couple of weeks ago, at the Hyatt Regency in Vancouver, British Columbia, Canada, some intriguing (but not really startling) data were presented at the annual Brain Development and Learning Conference: mothers who touch their babies more often can alter their offspring’s genetic expression and foster calmer babies who will grow up to be increasingly nurturing parents.  For those of us in the childbirth education arena, this is not surprising in the least.

For years, folks who promote safe, gentle birthing practices also tend to favor gentle parenting practices.  High-touch infant care falls under this category.  Famed pediatrician/author Dr. Sears calls it Attachment Parenting.  Others call it Kangaroo Mother Care (a philosophy which is often only thought of as being used with premies or newborns but can, in fact, be carried on throughout infancy).  Others, still:  Baby wearing.

The basic idea?  Keep your baby close by, offer skin-to-skin contact as a means of warming and/or comforting, bonding, teaching your child that you are there for her for the most basic of needs and that you are a tender, loving resource.

When our three kids were infants, we did the same thing I see thousands of other new parents doing:  we hauled our kids around in their detachable infant cars as if we were carrying around a utilitarian bucket of potatoes.  Because, let’s face it:  it’s easier, right?  No buckling and unbuckling the five-point harness every time we got in and out of the car.  No disturbing baby when he’s asleep in his bucket.

My friend who is an awesome mama, prenatal yoga instructor and doula, practiced baby wearing reverently with her two boys in their infancy.  As I observed her–always showing up with her little one snuggled into a wrap on her chest (or hip, as the baby grew) I pondered the realities:  doesn’t her back ever get sore?  Doesn’t she sometimes want her own space?

I imagine, the answer might have sometimes been ‘yes.’  But I also know that Gloria has a bond with her children like none other and was able to put aside the short term gains of her own comfort for the long term gains of what baby wearing likely fostered in the bond between mother and child.  And, I imagine, many “baby wearers” will tell you that they are comfortable wearing their babies–especially if fit with an appropriate sling/baby carrier.

Heres the thing:  with physical closeness comes psychological closeness, and you can bet those two boys of Gloria’s learned to trust their mama for their every need, early on.  Do kids who weren’t kept close as infants not trust their parents?  No, not necessarily.  But there are degrees of trust and psychological closeness and, where on that scale do you think a kiddo falls, who was kept close to his/her parents as an infant?  Just think of the inherent message baby wearing…attachment parenting…kangaroo care…sends:

I am here for you. Always. Your well-being is so important to me that I will make sure I am close by to recognize when you need something. You are not alone.

I also ponder the messages being sent to a baby who spends a ton of her time in her infant car seat:

My convenience is more important than your being comforted. I hold you (literally) at arm’s length because it is easier for me. I will take you with me according to my schedule (as opposed to being home for baby’s nap time–thus avoiding the concern about removing a sleeping baby from her car seat) rather than one that is more advantageous for you.

I know I am simplifying things here.  But really, when you consider implied messages contained in our daily actions, the messages we send can be deafening, and are sometimes different from that which we’d really like to be relaying.

I recently learned about a new product hitting the markets…designed for a similar rural population as the one I wrote about, here.  In an earnest attempt to create a life-saving product for premature babies born in developing countries  a product has been developed called the Embrace–a sleeping bag-looking “portable incubator” with a pocket in the back for an inserted heat pack.

I applaud the Stanford researchers who’ve come up with this, and their aggressive goal of saving hundreds of thousands of teeny tiny lives at $25 a pop (this is an entrepreneurial effort).  But I also have to wonder, what about good-old skin-to-skin contact?  Studies have repeatedly shown that babies’ body temperatures (and heart rate, breathing rate and blood sugar levels) remain more stable when held skin-to-skin vs. when placed in an incubator.  Would the money otherwise spent in R&D, developing new and newer baby warming technology be better spent on community health education campaigns, instead?  What do you think?

Uncategorized babywearing, kangaroo care, low-resource settings, parenting, skin-to-skin contact

[Editor's Note: This is the first post from our new regular contributor, Kathleen Kendall-Tackett, Ph.D., IBCLC. Kathleen writes about breastfeeding, perinatal/postpartum mental health, and psychoneuroimmunology (PNI). She writes on her site, Uppity Science Chick, "Few fields of study are more exciting (than PNI), and they touch a wide range of seemingly unrelated topics: trauma and health; breastfeeding; postpartum depression. PNI studies help us understand risk factors for chronic disease and can teach us all how to live healthier lives."  I'm very excited to welcome her here so we can all take part in these breath-taking discoveries. - AMR]

There is a movement afoot in childbirth education and perinatal health urging mothers to avoid nighttime breastfeeding to decrease their risk for postpartum depression. We know that if mothers follow this advice, it will have a negative impact on breastfeeding. But let’s put that issue aside for the moment and consider whether avoiding nighttime breastfeeding will preserve women’s mental health by allowing them to get more sleep. In short, is this good advice?

At first glance, it may seem to be. Since breast milk is lower in fat and protein than formula, we might assume that breastfeeding mothers sleep less than their formula-feeding counterparts. And when a mother’s mental health is at stake, avoiding nighttime breastfeeding might be worth the risk. However, recent research has revealed the opposite: that breastfeeding mothers actually get more sleep—particularly when the baby was in proximity to the mother. And that has major implications for their mental health. So if you want one more good reason for mothers to exclusively breastfeed their babies, here it is.

Breastfeeding Mothers Get More Sleep

In a study of 33 mothers at 4 weeks postpartum, Quillin and Glenn (2004) found that mothers who were breastfeeding slept more than mothers who were bottle-feeding. Data were collected via questionnaire that recorded 5 days of mother and newborn sleep. When comparing whether bedsharing made a difference in total sleep, they found that bedsharing, breastfeeding mothers got the most sleep and breastfeeding mothers who were not bedsharing got the least amount of sleep. Mothers who were bottle-feeding got the same amount of sleep whether their babies were with them or in another room.

Sleep patterns of 72 couples were compared from pregnancy to the first month postpartum via sleep diaries and wrist actigraphy (Gay et al., 2004). Most of the mothers were at least partially breastfeeding (94%) and 80% were exclusively breastfeeding. Most of the babies slept in their parents’ room and 51% regularly slept in their parents’ beds. Sleep and fatigue outcomes were not associated with type of birth, parent-infant bedsharing, or baby’s age. Mothers who were exclusively breastfeeding had a greater number of nighttime wakings (30 vs. 24) compared with mothers who are not breastfeeding exclusively. The exclusively breastfeeding mothers slept approximately 20 minutes longer than mothers not exclusively breastfeeding.

In a study of mothers and fathers at three months postpartum, data were collected via wrist actigraphy and using sleep diaries (Doan et al., 2007). The study compared sleep of exclusively breastfed infants vs. those supplemented with formula. In this sample, 67% were fed exclusively with breast milk, 23% were fed a combination of breast milk and formula, and 10% were exclusively formula fed. Mothers who exclusively breastfed slept an average of 40 minutes longer than mothers who supplemented. Parents of infants who were breastfed during the night slept an average of 40 to 45 minutes more than parents of infants given formula. Parents of formula-fed infants had more sleep disturbances. They concluded that parents who are supplementing with formula under the assumption that they are going to get more sleep should be encouraged to breastfeed so they will get an extra 30-45 minutes of sleep per night.

Not only do breastfeeding mothers get more sleep, but the sleep they get is of better quality. This study compared 12 exclusively breastfeeding women, 12 age-matched control women, and 7 women who were exclusively bottlefeeding (Blyton et al., 2002). They found that total sleep time and REM sleep time were similar in the three groups of women. The marked difference between the groups was in the amount of slow-wave sleep (SWS). The breastfeeding mothers got an average of 182 minutes of SWS. Women in the control group had an average of 86 minutes. And the exclusively bottle-feeding women had an average of 63 minutes. Among the breastfeeding women, there was a compensatory reduction in light, non-REM sleep. Slow-wave sleep is an important marker of sleep quality, and those with a lower percentage of slow-wave sleep report more daytime fatigue.

The most recent study was published in the journal Sleep, a major sleep-medicine journal not necessarily known for their support of breastfeeding. This was a study of 2,830 women at 7 weeks postpartum (Dorheim et al., 2009). They found that disrupted sleep was a major risk factor for postpartum depression. But here is where it really gets interesting. When considering what disrupted sleep, they found that the following factors were related to disturbed sleep: depression, previous sleep problems, being a first-time mother, a younger or male infant, and not exclusively breastfeeding. In other words, mothers who were not exclusively breastfeeding had more disrupted sleep and a higher risk of depression.

Conclusions

The results of these previous studies are remarkably consistent. Breastfeeding mothers are less tired and get more sleep than their formula- or mixed-feeding counterparts. And this lowers their risk for depression. Doan and colleagues noted the following.

Using supplementation as a coping strategy for minimizing sleep loss can actually be detrimental because of its impact on prolactin hormone production and secretion. Maintenance of breastfeeding as well as deep restorative sleep stages may be greatly compromised for new mothers who cope with infant feedings by supplementing in an effort to get more sleep time. (p. 201)

In sum, advising women to avoid nighttime breastfeeding to lessen their risk of depression is not medically sound. In fact, if women follow this advice, it may actually increase their risk of depression.

References:

Blyton, D. M., Sullivan, C. E., & Edwards, N. (2002). Lactation is associated with an increase in slow-wave sleep in women. Journal of Sleep Research, 11(4), 297-303.

Doan, T., Gardiner, A., Gay, C. L., & Lee, K. A. (2007). Breastfeeding increases sleep duration of new parents. Journal of Perinatal & Neonatal Nursing, 21(3), 200-206.

Dorheim, S. K., Bondevik, G. T., Eberhard-Gran, M., & Bjorvatn, B. (2009). Sleep and depression in postpartum women: A population-based study. Sleep, 32(7), 847-855.

Gay, C. L., Lee, K. A., & Lee, S.-Y. (2004). Sleep patterns and fatigue in new mothers and fathers. Biological Nursing Research, 5(4), 311-318.

Quillin, S. I. M., & Glenn, L. L. (2004). Interaction between feeding method and co-sleeping on maternal-newborn sleep. Journal of Obstetric, Gynecologic and Neonatal Nursing, 33(5), 580-588.

Uncategorized breastfeeding, cosleeping, postpartum, postpartum depression, sleep

[Editor's note: This is a guest contribution about the concurrent session at the Normal Labour & Birth International Research Conference titled Assessing Interactions Between Culture and Choice. Priscilla Hall (a second year PhD student at Emory University Woodruff School of Nursing), Esther Shoemaker (a first year PhD student in the Population Health program at the University of Ottawa), and Kathrin Stoll (doctoral fellow at the Centre for Rural Health Research) each presented their research. - AMR]

Thank you Amy and readers for allowing me the great opportunity of contributing my conference analysis to Science & Sensibility.

At no other conference has choosing between concurrent sessions been so difficult. However, from the moment the schedule was posted some weeks ago I knew there was one I had to attend. Assessing Interactions Between Culture & Choice focused on today’s generation of mothers and what shapes their perceptions, experience and consequently choices about birth.

Generation Y women are today’s young mothers and will make up the bulk of midwives’ clients in the approaching years. What shapes their perspectives on pregnancy and birth? And how will their expectations impact the way they choose to give birth?

Demographics and Influences

Generation Y is loosely made up of adults born between the mid 1980s and the mid 1990s In the conference session, we reflected on what influences this generation of women:

1. This generation is extremely comfortable with technology, having craved the “toys that make the noise” including Nintendo/Sega/Xbox game consoles, mini laptops and iPods. The toys of this generation often involve one-on-one interactions with a computer rather than a friend.

2. The “Audit Society” (Power 1997) is the norm for this generation. The 1980s saw an explosion of auditing activity in UK and American society. Teachers chart performance and activities of students, employees audited their own activities for their employers and health workers began recording up to the minute activities of their patients and one another.

3. To this generation “the most desirable women aren’t women at all – they’re girls.” The womanly shape, once held in esteem by the Greeks all the way up to pre-Twiggy models is seen as overweight to this generation. Smaller frames, straight figures and other pre-pubescent qualities are idealized by Generation Y women (or at least the media they consume). Not ironically, Gen Y has also been referred to as the Peter Pan Generation.

The first two in this hardly exhaustive list of predictors can help to explain how medicalized birth is quickly being assumed as the norm by today’s women. (And as Dr. Eugene Declercq of Boston University pointed out over lunch, the majority of U.S. women are satisfied with their maternity care.) In fact, as UBC doctoral candidate Esther Shoemaker points out from her mixed methods research of young women and new mothers, “Natural” birth to them does not equal “Normal” to us. Natural birth, to most of the women in her study, is synonymous with vaginal birth. Even if labor was induced, an epidural administered or forceps used, the women who gave birth vaginally experienced their birth as natural. I have witnessed this in my own Generation Y peer group of young mothers.

Further, the majority of those Shoemaker interviewed desired a vaginal birth in their antepartum interview, but also voiced an ambivalence about whether or not they actually would give birth that way when the time came. “If something happens I of course will have a c-section.” Oddly enough, perception of safety was not mentioned but the women said they would default to whatever their individual practitioner suggested.

In some cases reported, the practitioner suggested procedures to the Shoemaker participants that increased the degree of medicalized beyond what they expected for their birth. When this occurred, each of the participants changed their plans for their second birth. They either embraced the medical model completely or rejected the medical model in favor of a physiologic birth. So while they were ambivalent or passive first time mothers, they actively created their birth plans for subsequent children. The finding has important implications for today’s mothers as this was true for all Shoemakers’ participant’s whose birth experience was more medicalized than her birth expectation.

Intriguing findings in the studies:

1. Birth, to this generation, is, as UBC scholar Kathrin Stoll points out, a normal physiological process (71%), inherently risky and filled with “unavoidable complications” which necessitate technological interventions.

2. Of the women Stoll interviewed, 70% worried about how they and/or their partners would perceive their bodies during and after pregnancy.

3. According to Shoemaker, who studied what happened in subsequent births among women whose first births were more medicalized than expected, one of two extremes were common. The women would either fully embrace the medical model (e.g., plan a c-section with all the bells and whistles) or she planned to birth at home with no interventions.

The findings of this session’s speakers are all interesting and important for us as midwives, childbirth educators, and activists. When shaping our message about normal birth it is important to meet women where they are, use their language and respect their experience of the world and their bodies. How will we “market” normal birth as we are privileged to know it to the coming mothers?

About Katie Fulmer:

Like many of you, I have birth on the brain and care deeply about the health and wellbeing of our mommas. I am currently a student midwife with Illysa Foster, author of Professional Ethics in Midwifery Practice. My academic focus was Medical Anthropology as an undergrad at the University of Texas in Austin and I look forward to continuing my study of maternity and child care at the PhD level.

Uncategorized childbirth education, culture, Normal Labour & Birth Conference, qualitative

Last week, I attended the Normal Labour & Birth International Research Conference in Vancouver, British Columbia. With over 250 attendees from 23 countries, the conference set out to disseminate research about the nature of and optimal care for physiologic labor and birth, and to garner multidisciplinary perspectives on the implications for clinical practice, perinatal outcomes, education, management, collaboration, and policy.

I went as an agent of data dissemination. My job: to use social media (blogs, Twitter) to help make sure the conference proceedings didn’t just rattle around the four walls of the conference hotel, but got out to those in the field working to improve maternity care wherever we each are.

And I have some research I want to write about – really interesting, important research from every discipline you could imagine. But I left the three-day meeting thinking more about the (broken) link between evidence and practice than about any of the new, emerging evidence. I’ll get to the new research over the coming weeks, but first, a look at two stories that dominated the conference.

#1: Home birth on the defensive?

The plenary session by Dutch physician and epidemiologist, Simone Buitendijk, might have highlighted the unique model of midwife-led primary care geared toward planned home birth for low-risk women – a model that many birth advocates and researchers look to as a beacon of hope and reason. Buitendijk herself was co-author of the definitive study of planned home birth safety, a population-based study of over half a million births that found planned midwife-attended home birth as safe as planned midwife-attended hospital birth. And a Cochrane systematic review that came out around the same time as the Dutch home birth study provided definitive evidence that midwife-led care is superior to physician-led or shared models of care. So the Dutch have gotten it right, right? Time to celebrate and emulate? No, instead of a plenary about Dutch primary maternity care as a model to emulate, Buitendijk’s talk was a sobering call to action.

According to Buitendijk, in spite of this evidence (or perhaps in direct response to this evidence?) a well-coordinated media campaign in the Netherlands over the past year has emphasized the dangers of home birth, pointing to an entirely different body of evidence: comparative data showing that Dutch perinatal mortality rates are higher than those in other European countries. Although only about 30 of the 1700 Dutch perinatal deaths occurred at home, and perinatal mortality at the population level is affected far more by incidence and management of preterm birth and congenital anomalies than by the labor and birth care of low-risk women with term pregnancies, the Dutch mass media have made this a story about midwifery care and home birth. The result: the rate of home birth has dipped below 25% for the first time in Dutch history.

#2 VBAC is Back?

Eugene Declercq, who gives – hands down – the world’s most engaging and fun lectures about perinatal statistics, had the pleasure of making an 11th hour revision to his plenary talk on vaginal birth after cesarean (VBAC) thanks to ACOG, who released their new VBAC practice guidelines at 5pm the day prior. (Hat tip to yours truly for tipping him off about the new guidelines. I even got written into his plenary remarks, as the young woman with whom he had a “stimulating conversation” that led him to “stay up all night.” Har har, Gene!)

Anyway, we see in Declercq’s talk the familiar story of how VBAC rates increased briefly then plummeted in the early 2000’s as a result of new research on uterine rupture and, more precisely, an editorial by the ob-gyn editor for the New England Journal of Medicine saying that planned repeat cesarean is “unequivocally” safer than planned VBAC.

Research driving practice! That is, if the research (or overzealous interpretations of it) supports restricting practice.

Where’s the up-tick in VBAC rates when the Cochrane systematic review was published in 2004 concluding that “Planned elective repeat caesarean section and planned vaginal birth after caesarean section for women with a prior caesarean birth are both associated with benefits and harms?” The up-tick isn’t there because by then research wasn’t driving practice – ACOG guidelines calling for “immediately available” emergency obstetric care in VBAC labors were driving practice. And it wasn’t the NIH Consensus Development Conference on VBAC or the massive AHRQ systematic review underpinning the conference (i.e., evidence) that have been heralded as the beginning of the end of hospital “VBAC bans,” it’s ACOG’s (somewhat noncommittal) move away from the “immediately available” standard.

Evidence is not driving practice. Between evidence and practice there lives some kind of cocktail of power, money, activism, media, influence and serendipity (and preservatives). The relative strength of the ingredients dictates how practices evolve. Keeping with the cocktail metaphor, the VBAC plenary ended with an invitation to consumers and our advocates to shake things up – activism being the best hope for ACOG’s new guidelines to be used to drive meaningful change for the many, many childbearing women in the United States with scarred uteruses.

This all reminds me of a third plenary talk at the Normal Birth Conference – Patti Janssen’s lecture, Transforming Research into Policy: Ingredients of Influence, in which she quotes social scientist, Martin Rein.

It also reminds me of Kay Dickerson of the Cochrane Collaboration who said, “We are only to get evidence-based healthcare in this country through consumer activism.”

More on Janssen’s plenary, and updates on the research, coming soon.

Uncategorized ACOG, home birth, maternity care systems, NIH Consensus Conference, Normal Labour & Birth Conference, VBAC

My intention was to have daily round-ups of the Normal Labour & Birth International Research Conference on the blog and follow it with some in-depth pieces over the next few weeks.  But between a packed agenda, phenomenal networking opportunities, a gracious hostess who dragged me (neither kicking nor screaming) to see an international fireworks competition over the harbor last night, and jet-lag, I haven’t been able to blog one bit.  The good news is that I have about 6 months worth of blog posts I could write out of this conference. So stay tuned for some quick-hit pieces and some more depth analysis, coming soon!

In the meantime, 140-character-sized updates from the conference are constantly streaming on Twitter.

"Cascade of Normal" from Vicki Van Wagner's talk on midwifery in an Inuit region of Arctic northern Canada

Uncategorized Normal Labour & Birth Conference