February 21, 2001
Volume 3, Issue 8
Midwifery Today E-News
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Quote of the Week:

"There has never been any public outcry against the routine practice of separating newborn babies from their mothers, despite the fact that it has never been shown to be either safe or healthy for either mothers or babies."

- Suzanne Arms

The Art of Midwifery

One way midwives can facilitate strengthening the bond between the growing baby and the family: using a laundry marking pen, draw a picture of the baby on the mom's tummy, overlying the baby's actual position. Midwives can use this opportunity to teach about the usual positions of babies. Drawing the baby larger at serial visits is a concrete way for the family to track the growth of the baby. It helps partners and kids understand why mom looks the way she does, and gives them a visual way of identifying with the somewhat mysterious hidden little being inside.

- Sharon Glass Jonquil, Midwifery Today Issue 2

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News Flashes

A study funded by the Agency for Healthcare Research and Quality has determined that nearly one-quarter of women who undergo cesarean delivery may have had the procedure too early in their labor. Of the one million cesarean deliveries performed annually in the United States, about 294,000 are done because of lack of progress in labor. The up to 24 percent who had the surgery performed too early were dilated between 1 and 3 cm, which is contrary to the recommendation of the American College of Obstetrics and Gynecology that the cervix should be dilated to 4 cm or more before the diagnosis is made.

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A review of 17 controlled studies conducted between 1975 and 1985 compared newborn infants in the hospital who had routine contact with their mothers with those receiving additional contact. In 13 studies the additional contact occurred only during the first hour of life; 9 of these noted significant positive differences in the later behaviour of the mothers toward their infants. In the four studies in which the extra contact extended through the first three days of life, the mother-child relationship was measurably better in quality for the extra-contact infants than for the control infants at one month, one year and two years of age. Increased contact at any time during the first three days after birth (when the mother and baby spend this time in the hospital) produces a long-term improvement in the quality of the relationship between mother and child. Increased contact may in part make up for the marked deprivation that is a part of current routines in modern hospitals. There is some evidence that this, with the additional deprivation of insufficient contact, can have serious consequences for the child--both child abuse and failure to thrive without organic cause are found more frequently in infants who have been separated from their parents immediately after birth. A more recent review of 29 random control trials between 1972 and 1985 of restrictive versus unrestrictive mother-infant contact in the immediate postpartum period found strong evidence that restricting contact significantly reduced both subsequent maternal affectionate behaviour and subsequent breastfeeding.

- Marsden Wagner, Pursuing the Birth Machine, Ace Graphics, 1994.

Do fragile babies need incubators at all? One doctor working in an African hospital, where there were none, found that the mother herself made a perfect incubator--warm, soft, food on tap, the ever present comfort of the familiar heartbeat. This doctor saved 90% of babies as small as 4 pounds. Contrast this with the well-established research findings that mothers of babies spending time in neonatal care units find it more difficult to bond with their babies, suffer more postnatal depression, are still talking to their babies less a year later, and are more likely to batter those children.

Medicalised childbirth itself fills the intensive care cots by creating damaged babies: for example, babies born with respiratory distress syndrome caused by premature induction; ceasarean babies denied the positive benefits of the stress of vaginal birth; babies starved of oxygen--induced contractions; babies born floppy and full of artificial drugs. Babies deprived of the stress of normal birth are also deprived of B-endorphin needed to fall in love with their mother and learn their new environment.

- Margaret Jowitt, Childbirth Unmasked, Hartnolls Ltd. 1993.

The newborn can serve as a caregiver to its mother in a most essential and critical way. The mother and infant share a common need for generalized peristalsis during the first days following delivery, but particularly during the first few hours. If the newborn is permitted to nurse shortly after delivery, the flow of oxytocin is released, which in turn stimulates the letdown process, a form of peristalsis. Oxytocin is well known to stimulate uterine contractions, which are necessary to minimize the danger of postpartum hemorrhage and facilitate involution of the uterus. Sucking also promotes prolactin. Thus the nursing activity of the newborn not only facilitates the establishment of lactation but also serves to promote a state of equilibrium and physiological heaing in the mother.

- Ruth D. Rice, Ph.D. in 21st Century Obstetrics Now! NAPSAC, 1977.

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Question of the Week

Does anyone know the story on short umbilical cords? And how short is too short to deliver vaginally? Is it genetic, does it run in families, is it likely to occur more than once, is it nutrition-related, is it avoidable? I've known two ladies to have very short cords and they are afraid to attempt a vaginal delivery again.

- Amy Jones
Henderson, NV

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E-News Readers Speak Out on Bonding

Following are a question about bonding sent in by an E-News reader and answers offered by other readers.

A pregnant friend believes that if she cannot stay home all of the first 6 years of a child's life, she should work the first, and stay home the next 3 because the baby won't notice that she's gone in the first years of life. My response is emotional and moral, not scientific at all. I hesitated to tell her my opinion, deferring instead to what studies may have been done on the impact of leaving a child in early years. Have you heard anything, read any books or studies on this topic?

- Margaret Wallis

I once had a discussion with a friend who was the director of a private school. She said many parents put their children into private school for their high school years, hoping to get them into a good college. She felt this was going backward. If they were in private school for the lower grades, they would get a good base, good study skills and do well in the higher grades where ever they were. Well, I took that advice with my second daughter. She was in private school through 8th grade. She is now in public high school and tells me that in some classes, she is the only one who does homework. She has seen the difference.

Where am I going with this? If this mom stays home during the first three years when this baby is developing faster than she/he ever will again, her baby will have a stronger bond with its mom. The baby will develop a strong sense of trust, a solid base, so that when the mom does return to work, the baby will have grown to the stage where he/she wants to be more independent.

- Roni M. Chastain, RN, LCCE, FACCE
Long Island, New York

I would recommend reading psychological writing by John Bowlby and other attachment theorists. These researchers have studied early bonding and infant deprivation. Specifically, I suggest the book "A Secure Base" by Bowlby. Research done by Mary Ainsworth, Ana Freud, and Bowlby clearly indicates that the first years are the critical years in bonding and maternal infant bonding. Also share with this mother that three-year-old children are developmentally ready for socialization and some early peer relationships much as they would get in a daycare situation; infants are not. Most developmental psych research will get you to this point.
- christinaburden@hotmail.com

Please see two articles: Mothering Magazine Issue No. 74 "The Needs of Children" by Paul Klein, and "The Infant Daycare Experiment" in Mothering Magazine (don't know the issue number). Find them at www.mothering.com

- Anon.

The study of how babies experience pregnancy and birth has been ongoing for many years now: Otto Rank published "The Trauma of Birth" in 1929, in which he explored the long-term impacts of the experiences of pregnancy and birth on the psyche, and many other psychologists, psychiatrists and researchers have continued to explore this realm. There is now quite a body of solid scientific research demonstrating, for example, that twins develop a relationship style in utero that continues through their childhood, that fetuses whose eyelids are fused shut can either evade or bat away the amniocentesis needle, that children act out their births in their play and develop lifestyles into adulthood that, to the trained eye and mind, clearly echo patterns laid down in birth.

Psychologist David Chamberlain has done a magnificent job of gathering the majority of the research from various areas of science into over 40 publications: I would refer you to his valuable book, "The Mind of Your Newborn Baby." Dr. William Emerson has spent a lifetime studying and treating infants, children and adults for prenatal and birth traumas that include abortion attempts, conception through forced sex, drug/alcohol-addicted mothers, family crises, prior pregnancy losses, etc., and those displaying signs or symptoms of having suffered from interventive, complicated and/or traumatic births.

If this woman believes her baby remembers none of its first year, she will presumably be treating the little person she is growing inside her as a non-person also, and such a welcome doesn't bode well for bonding postpartum. I wouldn't just recommend books such as Chamberlain's (and his articles "The Sentient Prenate," "The Outer Limits of Memory" and "The Cognitive Newborn: A Scientific Update"--all of which are extremely well-referenced) and Aletha Solter's "The Aware Baby," but John Kennell and Marshall Klaus's book on bonding and the video from Johnson & Johnson on "the amazing newborn."

It sounds as though she knows very little about what she's getting herself into, and maybe isn't interested, which is scary! Studies have demonstrated that babies can distinguish their mother's face from other women's faces virtually from birth; that they turn toward pads soaked in their mother's breastmilk and not toward those of other women; that adopted babies know very well that their adoptive mothers are not their biological mothers and struggle with their emotions when this is not acknowledged by the adoptive parents, especially those who assume that because they are ready to love their new baby, their baby will be equally ready to love them--rather than crying inconsolably and grieving the loss of the mother s/he has spent nine months bonding with, experiencing every emotion of the biological mother (transmitted via hormones through the blood supply).

I'm sure there are a gazillion studies out there demonstrating the suitability of breastmilk for the nourishment of infants and the inferiority of artificial substitutes. Is she planning to pump all day? And the reason human breastmilk is so low in protein and fat is to ensure that human infants are fed frequently, thereby keeping them physically close to mother and in skin-to-skin contact many times per day, thus regulating their respiratory, heart and brain rhythms by proximity to their mothers' rhythms. It is no accident that infants develop the ability to digest foods other than breastmilk at around the same time that they become more mobile and less completely dependent on their mothers--human infants need an "in-arms" period that is approximately as long again as pregnancy because they are born so early in the gestational cycle because of our erect posture and relatively small pelvises.

The primary developmental task of the newborn is to bond with its parents and siblings: to learn that it can count on its caregivers to meet its needs--not only the biological needs, but the emotional, developmental and spiritual needs of the first stage of life outside the womb. Joseph Chilton Pearce, in "Evolution's End," says: "The intelligence of the heart is not some sweet sentiment but a primary biological necessity and the foundation of all bonding.... The mother is the first teacher of the heart...." Newborn humans are not able to regulate these systems well when at a distance from their mothers, and thrive when carried or "worn" by their mothers during the first six-plus months of life. The more contact, love, and appropriate stimulation they receive, the more their neurological systems develop, the smarter, more coordinated and more "contactful" they become.

Any parent who thinks a child won't remember its experiences of pregnancy, birth and the first years of life is deluding herself and doing the child she brings into the world a horrendous disservice loaded with long-term consequences. This mom could even be setting herself up for a traumatic birth: what baby would be eager to be born to a mother who's planning to leave her/him to the care of others on a daily basis from day one? It sounds to me, as a pre- and perinatal psychotherapist, that this mom needs to take a hard look at her own prenatal and early history and resolve issues that are already affecting the life of her unborn child through her unconsciousness about the personhood of her baby.

She needs some basic education in child development, at the very least, in order to understand that breastfeeding, the production of oxytocin--the "cuddle" hormone--the introduction of solid foods and the increasing mobility and sociability of a young child are perfectly designed by nature to allow for an initial period of intense, one-on-one bonding with parents, and then increasingly long separations from mother and in the care of other familiar caregivers (day care, pre-school, kindergarten, first grade) as the child gets older. If she will read them, there is quite a list of books out there on attachment parenting that explain the rationale for this approach to new parents. If she is unwilling to be educated, she may yet surprise herself after giving birth--all that oxytocin may put a whole different spin on her willingness to leave her baby to the care of others, so it would be a shame if she prearranged her postpartum life around plans for an early return to work.

An extensive website details a lot of what I've written above and more, and provides links to authors such as David Chamberlain. The site has an extensive listing of books, journals and videotapes in the field of prenatal and birth psychology. It is at www.birthpsychology.com.

- Claire Winstone, M.A., R.C.C.

The book "Being There: The benefits of a stay-at-home parent" by Isabelle Fox, Ph.D. with Norman M. Lobsenz, ISBN 0-8120-9490-5, specifically addresses the subject of childcare based on a number of studies. The basic point of the book is that children who have substitute caregivers during the first three years of life tend to lack the ability to bond with other people for the rest of their life. The book goes into detail about many specific problems this can cause.

- Kathy, Renton, WA

Look into brain-based learning. It is fascinating and "scientific." It explains why all the things mothers do in the first few years are so important for a child's social, emotional, educational development. There are certain windows of time for children to sort of set up the connections in their brains to prepare them for future learning, relationships, etc. It is scary that most of these windows virtually close by age two to three. Encourage this friend to stay home!

- Amy D.

QUESTION OF THE QUARTER for Midwifery Today magazine

Mamatoto: Motherbaby

How can midwives best facilitate the bonding process of motherbaby in pregnancy, birth and postpartum?

Deadline: March 31, 2001

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More on apprenticeship:

There is a new organization formed to support apprenticeships. MATA's mission: Support Apprenticeship. Mission statement: To gather together and share the wisdom of those training midwives through apprenticeship; to champion apprenticeship on the institutional level; and to provide other services for apprenticeship preceptors and apprentices to help make the midwifery apprenticeship training route successful and accessible.

Interested folks can join the egroup by going to www.egroups.com and looking up Midwifery Apprenticeship Training Alliance.

- Jenny Dempsey

There should be a Midwives of North America (MANA) board position that represents the interests of apprentices, like an apprentice advocate, to be a liason for serious problems that can occur in the preceptor/apprentice relationship. MANA can't get involved in every little scrabble, but if the problem is serious enough, and especially if the apprentice has already invested a year or two into the apprenticeship, she should have some recourse if she is about to get dumped. I would also like to see the recent Midwifery Student Bill of Rights be re-worked for apprentices too.

As part of the CPM credential, the preceptor should be required to have something in writing with the apprentice after the potential apprentice has attended a few births and it looks like a relationship is developing. NARM can offer guidelines on what to include in the "contract." It should include concerns like:

Money: Is the preceptor paying the apprentice? At what point does that start and how much? Or does the apprentice have to pay the preceptor for her education, like going to school?

Responsibilities: Does the apprentice get to go to all births? Must she attend all prenatal and postpartum checks? Let the preceptor know when she won't be available. What if the preceptor has several apprentices competing for work--who gets to do what?

Education: When does the preceptor sign the CPM application? Does the apprentice have to get her own "primary" clients, or does she use the preceptor's clients? What didactic requirements are there? How and when will these be assessed and "graded"? Does the apprentice have to get outside training, such as college classes, EMT training, childbirth education or LLL training?

Time frame: When will the apprentice know she is done? Only when her preceptor says so, after her numbers are complete? What if there is a conflict here?

Are there ethical requirements for the preceptor/CPM? Can her CPM be pulled or put on probation for unethical behaviour? There needs to be some kind of consequence to both preceptor and apprentice for misconduct. Currently everything favors the preceptor. If she gets mad, the apprentice can be "dumped" from the apprenticeship for anything or nothing at all, even after several years of work. What is her recourse? There should be a grievance procedure in place for serious situations. And the apprentice should expect a fair hearing and equal playing field to air her complaints.

NARM wants to encourage future midwives to work toward and achieve their CPM credential. I think they need to be more mindful of where the future midwives and CPMs come from. Mostly, from apprenticeships. It would be helpful to these apprentices and the future of direct-entry midwifery if that special and sometimes volatile relationship could be handled more fairly.

- Vicki Johnson, former apprentice, now midwife

More on excessive bleed:

I have found that a postpartum tea brewed with shepherd's purse, false unicorn root, and a little licorice for flavor helps the mother bleed less in the weeks following delivery. However, we have to remember that often in our culture new moms do not get the support and help they need after giving birth. Most women who are bleeding for weeks and weeks after their birth are simply doing too much and need help in figuring out how to get more rest. Sometimes this means getting outside help; sometimes it is just a matter of helping them get organized and learn to let go of doing it all. Another thing I have learned is to check the mom's labwork prenatally for the platelet count. This is directly linked to her blood clotting ability. I worked with a vegan woman with a very low platelet count. She bled for a prolonged amount of time when she got a cut. We worked on her diet. She increased her protein intake and began eating eggs. Her platelet count went up and she had a beautiful homebirth with a minimum of blood loss. The best source of information on this subject was Anne Frye's book, Understanding Diagnostic Tests in the Childbearing Year. I have also used the Chinese herb yunan piao for postpartum bleeding with very good results.

- Lori Land

I was intrigued by the discussion of excessive post birth bleeding and was glad to see that someone mentioned the power of suggestion. Please do not scoff; when I first heard of this I thought "no way!" But I've used it and it has worked every time. You can tailor your approach to the personality of the woman. For those open to "alternative/complementary therapies" I look closely into the woman's eyes and say "stop your bleeding." For those more hesitant about such things I will walk her through a visualization of her uterus as a ball that can expand and contract, and I have her concentrate on having it contract, etc. Those more in tune with their bodies are often more successful in stopping the bleeding and keeping it stopped; with others it may start up again if they don't stay tuned in. You may need to resort to herbs or stronger meds. but I believe suggestion should always be the first line with excessive postpartum bleeding.

- Cathryn

I have used shepherd's purse for a particular woman and it has not been successful. I would appreciate hearing other suggestions, preferably for herbs.

- Anon.

What is meant by bleeding excessively? For some women 1/2 cup could lead to shock but for some losing even 3 cups can be well tolerated. Maybe she's really good at making extra blood supply in pregnancy. How does this woman tolerate the bleeding that occurs? Does she have problems with shock symptoms, recovery, or breastmilk supply postpartum? The standard "2 cups" is only a guide; look at the woman herself.

Bleeding "excessively" may be the result of an imbalance of the woman's physiology which seeks to eliminate excess heat (called Pitta in Ayurveda) from her body. Have you heard the old midwives' tale that redheaded women bleed more? They are also more likely to have excesses of pitta. The very blood building supplements which she took to prevent hemorrhage COULD actually increase the chance of bleeding if they increase that fire in her that wants to come out. In Ayurveda and in Chinese medicine, balancing an individual according to her particular constitution will reduce this kind of situation. Other more complex factors can also lead to excess bleeding, such as apana prana disorder. If there is a practitioner of Ayurveda or Chinese medicine available, this woman may greatly benefit from their help.

- Terra Richardson, Ayurvedic practitioner & midwife
Boulder, CO

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