Editor’s note: This article first appeared in Midwifery Today, Issue 101, Spring 2012.
Subscribe to Midwifery Today Magazine
In order to adequately explore Kangaroo Care, it is helpful to first define certain practices, concepts and verbiage through the perspective of ethnopediatrics. We will also examine the source of conventional ideas on premie care so that we might compare and contrast the rationale and efficacy behind both ways of attending to our most fragile of babies. We will look at the importance of touch, baby wearing, breastfeeding and, perhaps most importantly, the idea that we must return to the wisdom that views mothers and newborns as part of a symbiotic relationship.
Mothers have always kept babies close and, through ethnopediatrics, science is now exploring why mothers do this. Ethnopediatrics combines anthropological, physiological, psychological and sociological information to “initiate the study of parents and infants across cultures and to explore the way different caretaking styles affect the health, well-being and survival of infants” (Small 1999). From the study of ethnopediatrics, we now understand that babies are not just small adults or empty vessels. They are born interactive with an instinct to survive. Both mother and baby are hard-wired to seek each other out for survival. Crying may be a baby’s only mode of communication, but he uses it effectively to signal his need to be held, to be warmed, to be fed. British psychologist John Bowlby speculated that if “to lose touch was death” there must be ramifications in disturbing this basic instinct (Hrdy 1999). Bowlby began work in the 1950s to find out what those ramifications might be. He saw that an infant’s determination to be in constant contact with its mother has changed little over millions of years and concluded that the mother is the baby’s environmental niche. No matter what environment the mother is in, the infant’s entire world consists of mom. In Our Babies, Ourselves, Meredith Small describes mother and infant as “a biological system of interdependence that seeks the same goal—stability” and that “this goal is achieved by mutual regulation, by reciprocity” (Small 1999). Later, she states the obvious: We would never separate other mammals from their young at birth and expect them to adequately care for their young after disrupting their initial bonding process. Behavioral disruption of human bonding likewise presents unnecessary barriers and issues. If our behaviors across cultures and throughout time were similar or the same, there may be a reason that we have adapted as we have. Might it be detrimental to interfere with millions of years of successful survival?
The Importance of Touch
In his book Prenatal Parenting, neonatologist Dr. Fred Wirth writes that “the shape and architecture of premature infants’ brains are sculpted by what they experience in the intensive care nursery” (Wirth 2001). He has witnessed how separation causes disruption of a previously well-organized nervous system in premies who crave contact with their mothers. We know from experiments with monkeys conducted by Harry Harlow in the 1970s that touch is important. When baby monkeys were given a choice between a hard mother substitute made of wire that provided food and a soft mother substitute covered in cloth that did not, they chose the soft mother. Studies of feral children show that without touch, human babies either suffer from failure to thrive or failure to socialize in a way that allows them to integrate into society. Babies are born knowing that being in mom’s arms is necessary for survival.
The in-arms approach to being with our babies is adaptive to survival. It is a generally accepted theory that human infants are born before they have finished developing predominately due to two factors: we have larger brains than other primates and we walk upright. An inordinate amount of maternal energy would be required to grow a fully developed infant brain, and more importantly the size of that brain would not pass easily, if at all, through the upright pelvis of the bipedal mother. After birth, brain growth of the human infant surpasses that of any other mammal during the first year of life. Thus, primate anatomist and paleontologist R.D. Martin suggests that human gestation is actually 21 months long, consisting of nine months of pregnancy followed by the first 12 months of a baby’s life (Small 1999).
When we use a global, ethnopediatric perspective, we find that certain ways of being with our babies have historically been adopted across cultures because these behaviors optimize infant survival. These behaviors tend to be practices that are widely accepted. For instance, attachment parenting is essentially all about survival. Baby wearing and on-demand breastfeeding are central to attachment parenting. Why? Because in the same way that babies know they need mom, mothers know that babies need to be warm, safe from harm and fed frequently. Dr. Wirth describes the long- and short-term damage done if a mother is emotionally inaccessible or physically unavailable for her infant as devastating.
A History of Separation and the Incubator
For millions of years mothers have done what comes naturally because humans are programmed for survival. Unfortunately, for the last century or so, our instinctive parenting behaviors have been supplanted by cultural expectations that are fundamentally counterintuitive. Before Harlow’s baby monkey experiments in the 1970s, before ethnopediatrics verified what mothers have always known, human babies and premature babies in particular were used in a number of experiments that were allowed to continue for nearly 44 years. Experiments that placed premature babies on exhibit in sideshows directly relate to how premature infants are cared for today. It is important to look at these practices in order to appreciate the wisdom of Kangaroo Care. I would also like to briefly explain the origin of separation in the motherbaby dyad as well as the history of the incubator.
In the 1890s, a Parisian physician named Pierre Budin was working to improve outcomes with premature babies. It was understood at the time that three main factors led to high premie mortality rates: difficulty with temperature regulation, feeding problems and susceptibility to disease. Two of these issues are somewhat linked and were addressed with practical solutions. Feeding babies human milk was the norm, and even if mothers did not supply milk to their own infants, wet nurses did, and this alone would have provided the baby with some immunity. In addition to providing human milk, wet nurses were instructed in special hygiene routines to minimize contamination, and sick infants were separated from healthy ones for the same reason. The issue of temperature regulation remained unresolved until another French doctor, Martin Couney, visited a zoo and observed warming chambers used to incubate poultry. He asked that the zookeeper build a similar contraption large enough for premature babies (Silverman 1979). In 1896 Couney began exhibiting premature babies in the World Exposition in Berlin and by 1903 he was touring amusement parks in the US with his incubator babies. Incubators were touted as marvels of science, as we see from an article in The Lancet on May 29, 1897:
The main feature of this new incubator is the fact that it requires no constant and skilled care. It works automatically; both ventilation and heat are maintained without any fluctuations whatsoever, not only for hours, but even for days. The incubator need not be touched for these purposes, and the only attendance necessary is that needed for feeding and washing the infant…. Only air taken outside the building is supplied to the infant within the incubator (The Lancet, 1897, 1490–91).
The displays continued until 1940. These spectacles took place at a time when many believed that babies didn’t have the ability to think, see or feel pain. The practice of separating premature babies, and eventually all babies, from their mothers and placing the infants in incubators and warming beds came from these experiments. The incubator system presented Couney with a few challenges, however. The babies were returned to the parents when they reached a weight of five pounds, and Couney noted that the parents seemed to have little interest in their babies and that they did not seem appreciative of his work.
Eventually, improvements were made. It was thought that the incubators might confine babies, prohibiting adequate stimulation of their vestibular system, so beds that oscillated were produced. TLC (tender loving care) time was instituted, in which nurses were scheduled to touch babies. There were concerns that a baby in an incubator might only hear the sound of machines, so a recording of the mother’s voice was piped in. The premise that babies, especially premature babies, needed to be kept warm because they are unable to adequately regulate their own temperature was spot on. Looking to a scientific way to warm babies instead of to the ancient wisdom of mothers was where we made a wrong turn. Consider the “improvements” above and note: A mother does all that and more. We must look to science to support what nature has provided for survival instead of allowing science to supplant nature. Nature has been doing a fine job of insuring survival as long as all possible variables can be optimized. For instance, in the case of marsupials, the babies are born very underdeveloped. Therefore, nature has provided mothers with pouches to keep the babies warm, fed, portable and safe.
Kangaroo Care is reclamation of that inherent wisdom, combined with the application of knowledge gleaned from ethnopediatrics. With Kangaroo Care, the biological and emotional needs of the baby and the mother are met, and the desire for care providers and institutions to provide the best care with the least expense is achieved. In order to understand how these goals are accomplished, let’s consider the components, rationale and outcomes of Kangaroo Care. In 1978, rising morbidity and mortality rates along with a shortage of caregivers and resources in Bogota, Columbia, led Dr. Edgar Rey Sanbriadue to institute protocols that would come to be known as Kangaroo Care or Kangaroo Mother Care (Conde-Agudelo, Belizán and Diaz-Rossello 2011). He suggested that mothers maintain continuous skin-to-skin contact with their babies to keep them warm and to provide exclusive breastfeeding on demand. Kangaroo Care now consists of three core components: skin-to-skin contact (baby wearing), breastfeeding and a critical perception shift—seeing the mother and baby as a dyad. By keeping the baby next to the mother’s chest, the baby is in close proximity to the breast, facilitating breastfeeding. The very act of breastfeeding is calming to the mother’s central nervous system, delivering a “potent and safe analgesic” (Kroeger 2004) in her milk. In addition, the milk of a mother delivering a baby prematurely differs in composition to the milk of a mother delivering full term (Bsumslag and Michels 1995). Fathers also participate in baby wearing with positive results. Obviously, parents are the original incubators! Parents provide warmth to premies that are unable to maintain their own body heat. Regular skin-to-skin contact with a parent regulates baby’s heart rate and reduces the production of stress hormones, which help regulate blood sugar levels (Moberg 2003). Babies even grow better and faster. The long term benefits of Kangaroo Care are recognized by the World Health Organization (WHO). Using the Cochrane database to determine which forms of reproductive health care may be beneficial or harmful, Kangaroo Care is listed in the Reproductive Heath Library as likely to be beneficial and is “also found to increase some of the measures of infant growth, breast-feeding and mother–infant attachment associated with reduced likelihood of illness at six months…” (Bergh 2011).
Kangaroo Care is beneficial even for the very premature infant. Melodi was born between 23 to 25 weeks gestation. She weighed 1 lb 2 oz. Those caring for Melodi used the Kangaroo Care approach and, now at age 10, the only sequela relating to her premature arrival is severe nearsightedness. Her mother reports she is a great reader and a normal child in every way.
We need to preface Heather’s story by honoring her first birth. Baby Kyra was born after preterm premature rupture of membranes (PPROM) in a small hospital in a rural area of the US. She was 1 lb 1 oz, about the same size as Melodi. Both parents saw the baby move before the nurse quickly cut the cord and left the room with the baby without a word. Kyra was deemed a stillbirth as she never drew a breath. The parents were allowed to spend as long as they wanted with their still daughter, grieving. Two years later Heather became pregnant again. She had an uneventful pregnancy to 36+ weeks by her calculations, 34 weeks via ultrasound, when she experienced PPROM again and went to the hospital right away. Typically she would have been transported to a larger hospital because of the ultrasound dating, but because she progressed so quickly it was decided that she should remain at the same small community hospital in which she had birthed Kyra two years earlier. A quick internal exam revealed the baby was breech. The OB was skilled in breech deliveries but hesitant with a probable premie. She ordered an ultrasound and found a short double nuchal cord. Mom was 8 cm already, but understood a caesarean would be necessary with this trifecta of complications. Her husband kept Heather as calm as possible as it became apparent that this baby was in distress immediately following surgery. Heather started to experience flashbacks as CPR was initiated on her daughter and her baby, Kaiya, was taken away just like the first daughter she had lost. Heather knew about Kangaroo Care and was happy with the appropriate use of technology and determined to provide Kaiya with the best start possible. For her own emotional well-being, she did not want to be out of sight of her healthy newborn daughter. However, she was not at one of the 200 NICUs that embraced Kangaroo Care.
Despite repeated requests, four hours passed before Heather saw her baby, and then for only a few minutes. Kaiya weighed 5 lb 15 oz and the pediatrician declared her term or nearly so by all indications. She was breathing well, but the monitor alarm kept going off. The nurse on duty told the dad that while the monitor was beeping it meant nothing because she could see the baby was breathing fine. The heat lamp in the warmer wasn’t working either, yet Kaiya was placed under it. Dad stayed with her and said that not one person interacted with Kaiya other than to poke her for glucose checks. During this time, one glucose check was low, so she was given a bottle. Heather was told that she was not allowed to breastfeed the baby because it would “wear the baby out” and that she would be provided with a pump. At six hours after birth, Heather was allowed less than five minutes to try to feed her baby. Within eight hours of her surgical birth, Heather endured one of several painful walks down to the nursery intending to sit and Kangaroo Care her baby, but she was quickly forced to leave the nursery each time she attempted this. Finally the night nurses came on shift and Heather found some support. She asked her pediatrician if there was any reason her baby could not be with her. She was told there was not and that she had a healthy baby. That first night, however, Heather was struck with an epidural headache requiring a blood patch, leaving her incapacitated. The next morning, the day nurse was back on shift and insisted that it was doctor’s orders that Kaiya stay in the nursery. Although Heather fought for her right to use Kangaroo Care for her daughter, all of her attempts were thwarted during the three days she spent in the hospital.
This is obviously an extreme situation. While correlation does not equal causation, with what we know about the benefits of Kangaroo Care, it is not unreasonable to conclude that certain problems may likely stem from the above scenario. Considering this mother’s previous history, not being allowed to be with her baby led to a very difficult postpartum period. By 9 months postpartum, Heather was diagnosed with posttraumatic stress disorder (PTSD) and postpartum depression (PPD) and is now on Prozac. She has a healthy baby who survived this ordeal, but how has the dyad been altered? Kaiya had difficulty latching to the breast and was a challenge to parent for months, displaying physical and behavioral issues. Heather was persistent and pumped every 3–4 hours for 6 months, so the baby got only mother’s milk, but she was never able to breastfeed her daughter. Heather held her baby as much as possible to try to make up for lost time, and Kaiya seems like a happy baby thanks to her determined and loving parents, but what happens to children who do not have such unconditional support and assistance?
This story has personal relevance as Heather is my sister, and I’ve seen her nearly come undone as a result of those first few days. What if that small hospital had known more about Kangaroo Care? What if this mother who did know about it had been supported? Would it have made a difference? Heather wants to help others. Her hope is that by providing a personal glimpse into her life, her experience can help people see the importance of not disrupting the motherbaby dyad. The way we approach and take part in our first interactions with others impacts those individuals for the rest of their lives, and our babies are no exception.
Keeping this in mind, if you are in a facility that already supports Kangaroo Care, fantastic! Is there a way you can reach smaller facilities near you? How can you spread the word that trying to artificially replicate a mother’s loving embrace, perfected over millions of years for the sake of survival, is a fool’s journey? Nature or nurture does not determine who we are as individuals—we are shaped by a combination of both. Nurturing optimizes the survival of an individual of the species and the species as a whole. In supporting the motherbaby dyad, we strengthen familial bonds, which expand societally and globally. We truly have the ability to make the world a better place, one motherbaby at a time.
- Bergh, A-M. 2011. “Kangaroo mother care to reduce morbidity and mortality in low-birth-weight infants.” The WHO Reproductive Health Library; Geneva: World Health Organization.
- Bsumslag, Naomi, and Dia Michels. 1995. Milk, Money, and Madness: The Culture and Politics of Breastfeeding. New York: Bergin; Garvey.
- Conde-Agudelo, A, JM Belizán, J Diaz-Rossello. 2011. “Kangaroo mother care to reduce morbidity and mortality in low birthweight infants.” Cochrane Database of Syst Rev 2011 (3): CD002771. DOI: 10.1002/14651858.CD002771.pub2.
- Gerhardt, Sue. 2004. Why Love Matters: How Affection Shapes a Baby’s Brain. East Sussex: Brunner-Routledge.
- Hrdy, Sarah. 1999. Mother Nature: A History of Mothers, Infants, and Natural Selection. New York: Pantheon.
- Kroeger, Mary. 2004. Impact of Birthing Practices on Breastfeeding: Protecting the Mother and Baby Continuum. Boston: Jones and Bartlett.
- Larimer, K. 1999. “Kangaroo Care Benefits.” Accessed April 21, 2011. http://www.prematurity.org/baby/kangaroo.html.
- March of Dimes. “Holding Your Baby Close: Kangaroo Care.” March of Dimes.
- Moberg, Kerstin. 2003. The Oxytocin Factor: Tapping the Hormone of Calm, Love, and Healing. New York: Da Capo Press.
- Silverman, William A. 1979. “Incubator-Baby Slide Shows.” Pediatrics 64 (2): 127–41.
- Nyqvist, KH, GC Anderson, N Bergman et al. 2010. “State of the art and recommendations. Kangaroo mother care: application in a high-tech environment.” Acta Paediatr 99 (6): 812–19.
- Odent, Michel. 2003. Birth and Breastfeeding. East Sussex: Clairview.
- ———. 2002. Primal Health: Understanding the Critical Period between Conception and the First Birthday. East Sussex: Clairview.
- Small, Meredith. 1999. Our Babies, Ourselves: How Biology and Culture Shape the Way We Parent. New York: Anchor Books.
- The Lancet, 1897. “The Use of Incubators for Infants.” 149 (3848): 1490–91.
- University of Michigan Health System: Holden Newborn Intensive Care Unit. “Kangaroo Care.”
- Wirth, Frederick. 2001. Prenatal Parenting: The Complete Psychological and Spiritual Guide to Loving Your Unborn Child. New York: Harper Collins.