Symposium
Chairs: John H. Kennell and Susan K. McGrath
Discussants: Ronald G. Barr and John H. Kennell
Over the course of history, human beings have developed practices that increase the likelihood that newborn infants will thrive, thus assuring the survival of the species. In the twentieth-century, technological advances have often taken the place of longstanding, customary perinatal practices (for example, the shift toward bottle feeding of formula in place of breastfeeding). The acceptance of modern methods frequently occurs without empirical evidence to substantiate the benefits of such changes. Data from studies in three different aspects of maternal and infant health demonstrate that eliminating centuries-old customs in favor of modern methods may inadvertently result in outcomes that are detrimental to mothers and babies. First, reintroducing continuous emotional support for a woman in labor provides an alternative method for managing the stress and pain of labor. The contrast between modern birth environments and historical human birth practices will be presented from an anthropological perspective. A large randomized controlled trial of continuous labor support in a U.S. population demonstrated that such labor support decreases cesarean deliveries and improves maternal-infant interaction at two months. Second, a cluster-randomized trial in 31 hospitals in the Republic of Belarus examined the effect of simple changes in hospital routine on breastfeeding rate and success. The intervention was modeled on the WHO/UNICEF Baby-Friendly Hospital Initiative and utilizes techniques practiced by generations of women. Finally, a laboratory study comparing the cosleeping and solitary sleeping of mother-infant pairs demonstrated that cosleeping infants gain experience in self-arousal, an ability which may be an infant's best defense against hypoxia due to apnea. The results from these three studies indicate the importance of applying evidence-based methods to examine the benefits of longstanding practices in the area of maternal and infant health. Customs that have been practiced throughout human existence have an evolutionary basis with important benefits to mothers and infants, and these practices should be preserved in the push toward modernization and technology.
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Because every mother and infant can potentially benefit from the best possible start in life, much effort is expended to ensure that the birth process results in a healthy and optimal outcome. In many circumstances, however, the emotional needs of the mother at this time are given secondary consideration to her medical needs and those of the infant. Ideally, both would be served. If childbirth is placed in the context of human evolution, a perspective referred to as 'evolutionary obstetrics,' we see that there are often mismatches between what human evolved bodies and minds 'expect' and the contemporary environments in which most women deliver their infants. I argue that part of the ancient legacy of parturient women is to experience the pain and anxiety that normally lead them to seek emotional support at this time of great vulnerability. But in many hospital settings the needs for emotional support at birth are not being met.What evolutionary value is there to seeking companionship during labor and delivery? Human anatomy that allows for two-legged walking (bipedalism) means that the fetus emerges from the birth canal in a way that makes it difficult for the mother to deliver her alone in the way of other mammals. The orientation of the infant at birth interferes with her ability to guide the infant out, wipe mucus from its face and nose, and remove the umbilical cord if it is wrapped around the neck. I argue that the human response to the challenge of this 'obstetrical dilemma' of bipedalism was to seek assistance at birth. This assistance, in turn, reduced mortality and morbidity associated with birth.Problems may arise today when the normal and expected stress, anxiety, and pain of labor and the strongly felt need for companionship are not ameliorated. The common response to these stresses in the recent past has been drugs to suppress the sensations, but these drugs have negative effects on the fetus, so their use is often restricted. An obvious alternative is to provide supportive companionship for every laboring woman. Recent research suggests that providing companionship to women in labor not only contributes to reducing stress and enhancing positive feelings about the birth, it also serves to improve biomedical outcome. This paper argues that meeting the deeply rooted, but normal and expected, emotional needs of women at birth can potentially enhance physical and emotional health of both mother and infant and set the stage for optimal development of the mother-infant relationship.Human infants also have an evolutionary legacy, one that includes almost constant contact with a caregiver, exclusive and frequent nursing, co-sleeping, and absence of nutritional and emotional competition from siblings for approximately four years. In modern, Western societies, the lives of human infants rarely approximate this ancestral legacy. The evolutionary perspective offers a way of understanding the results of the studies of co-sleeping, breastfeeding, and doula support during labor and delivery that follow.
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Throughout history and across many cultures, women have rarely gone through childbirth without supportive female companionship at delivery. Childbirth practices in the United States have undergone dramatic changes in the last century. Labor and delivery moved out of the family environment and into the realm of the hospital and medical staff. As various forms of analgesia became available, the laboring woman's need for human support was thought to have been met by having her husband accompany her. Several randomized controlled trials (RCTs) have demonstrated that providing a laboring woman with the continuous support of a woman experienced in labor and delivery (a doula) has a positive effect on perinatal outcome. In spite of these findings, women in the United States rarely choose to have a doula support them through labor and delivery, but rely on epidural analgesia to manage the pain of labor. A RCT of 427 low-risk primigravidas was conducted in a large teaching hospital in Houston, Texas, to compare the perinatal effects of continuous doula support and epidural analgesia. 87% of the patients were Hispanic, 7% were African-American, mean maternal age was 21 years, mean maternal education was 9 years, and all of the patients were considered low-income. At the first indication of pain, patients in the Control group received narcotic analgesia and epidural analgesia was given if needed or requested by the patient; patients in the Doula group received continuous doula support and were given narcotic analgesia when pain was first indicated. Epidural analgesia was provided to patients in this group at their request or if the medical staff felt it was needed. Patients randomized to the Epidural group received epidural analgesia at the first indication of pain after they were 4 centimeters dilated. These patients could also receive narcotic analgesia if they indicated pain prior to 4 centimeters dilation or if the epidural was not effective enough. Patients in the Doula group had significantly different perinatal outcomes, with less pitocin, fewer mothers developing fever, shorter average labor length, fewer forceps or vacuum deliveries, and a remarkably low number of cesarean deliveries (see table). Epidural (N3D155) Control (N3D138) Doula (N3D127)Pitocin 45.8 % 42.8 % 25.2% p < .01Maternal Fever 29.6 23.5 12.3 p < .01Forceps/Vacuum 24.8 17.2 12.2 p < .01Cesarean Dlvry 16.8 11.6 3.2 p < .01 At 2 months postpartum, 135 of these subjects were seen in a home visit to observe mother-infant interaction. Women who had doula support (N3D42) demonstrated more positive interactions with their infants at 4 of 5 observation points (p<.001) than did women who labored without a doula (N3D93). Continuous doula support during labor offers an alternate method of managing labor that decreases the chance of cesarean delivery and promotes positive mothering behavior at 2 months postpartum. All laboring women should be provided with continuous doula support for its positive effect on obstetric outcome and future parenting behaviors.09
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This presentation will summarize the objectives, methods, and results of a cluster-randomized trial of a breastfeeding promotion intervention modeled on the WHO/UNICEF Baby-Friendly Hospital Initiative (BFHI). Thirty-two hospitals and their affiliated polyclinics in the Republic of Belarus were randomized to receive 9-12 months of FHI training involving medical, midwifery, and nursing staffs (experimental group) or to continue their routine practices (control group). All breastfeeding mother-infant dyads were considered eligible for inclusion in the study if the infant was born at > 37 weeks gestation, weighed > 2500 grams at birth, and had a 5-minute Apgar score > 5, and neither mother nor infant had a medical condition for which breastfeeding was contraindicated. A total of 17,795 mothers were recruited at the 32 sites, and their infants were followed up at 1, 2, 3, 6, 9, and 12 months of age. To our knowledge, this is the largest randomized trial ever undertaken in the area of human milk and lactation. Monitoring visits of all experimental and control maternity hospitals and polyclinics were undertaken prior to recruitment and twice more during recruitment and follow-up to ensure compliance with the randomized allocation. Major study outcomes include the occurrence of > 1 episode of gastrointestinal infection, > 2 respiratory infections, and the duration of breastfeeding, and were analyzed according to randomized allocation ('intention to treat'). To assess data quality, we selected a random sample of study infants at each site, extracted their polyclinic medical records, and interviewed their mothers to assess concordance of principal study outcomes with those recorded on our study forms. One of the 32 sites had to be dropped from the trial because of apparently falsified follow-up data, as suggested by an unrealistically low incidence of infection and unrealistically long duration of breastfeeding and as confirmed by subsequent data audit. Of the 17,046 infants recruited from the 31 remaining sites, 16,491 (96.7%) completed the study and only 555 (3.2%) were lost to follow-up. Results of the data audits and for the major study outcomes were not available for public release at the date of abstract submission, but significant results will be presented at the ICIS conference.
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Results of a three year NICHD funded study in which 70 routine cosleeping and solitary sleeping mother-infant pairs alternated between bedsharing and sleeping in separate rooms over three consecutive nights in a sleep laboratory are reported. Infrared video photography combined with physiological monitoring of mother and infant simultaneously, while sleeping together and apart reveal significant differences between the solitary and cosleeping (bedsharing) environments, some of which appear to affect the infant's neurodevelopment and contribute to both maternal and infant well-being. For example, infants who routinely slept with their mothers exhibited more transient EEG-defined arousals while sleeping alone (as well as when sleeping with their mothers) than did routinely solitary sleeping infants when cosleeping. Moreover, there was a significant decline in the average bout duration of stage 3-4 (deep sleep) while cosleeping, especially if the infant was a routine bedsharer. Routinely bedsharing infants breastfed twice as frequently each night than did routinely solitary sleeping breastfeeding infants, and for three times the total nightly duration. Both mothers and babies who routinely coslept showed greater sensitivity to each other's presence, as measured by the number of overlapping arousals (within 2 seconds of one another). Bedsharing mothers spent less time in deep stages of sleep and more time in light stages (stage 1-2) of sleep than did solitary sleeping mothers, but both the bedsharing mothers and infants slept for longer total time. Routinely bedsharing mothers evaluated their bedsharing sleep more positively than did routinely solitary sleeping mothers following their routine solitary experience. Bedsharing babies faced in the direction of their mothers' bodies for nearly the entire night, but showed no preference for either side when they slept alone. The decline in Stage 3-4 sleep and the increase in partner-induced arousals among infants while cosleeping may provide infants with some practice in arousing. Such practice in arousing, particularly for those infants with arousal deficiencies, may better prepare infants to resist a serious respiratory crisis such as SIDS during sleep, since arousing is an infant's major defense against hypoxia precipitated by prolonged breathing pauses or apneas.