Previously we discussed the psychological aspects of the baby’s inward/outward orientation. In this article, we will examine some of the physiological aspects of the two carrying positions. At this stage, no recent solid scientific evidence (such as controlled comparative studies over several years) exists to support either position. So, we have to reason based on the existing evidence of  babies’ developing physiology and interventions that correct musculoskeletal abnormalities.

Let us begin by defining what exactly we mean with inward or outward facing positions.

In the inward-facing position, the baby is carried upright, with its front facing inward, the legs positioned in the so-called spread-squat position, i.e., towards the caregiver, legs straddled and knees pulled up. The baby can be placed on the front of the caregiver, on the hip or on the back. Common to these positions is the fact of the baby’s front being held against the caregiver – and the spread-squadposition.

In the outward facing position, the baby’s front is no longer facing toward the caregiver. Instead the baby has its back facing the caregiver, the legs hanging almost straight down, akin to the position of a parachuter.

At the time a baby is born, its skeleton is not fully developed and  as such is malleable and susceptible to environmental influences. One of the conditions pediatricians will check regularly for in the child’s first year is developmental dysplasia of the hip. It is called “developmental,” because the condition may or may not be present at birth, but it can develop over time, often unnoticed. If not caught and corrected, hip dysplasia can have serious long term effects as the child grows into adulthood.

Interestingly, when a child is diagnosed with hip dysplasia, the very position in which it is placed via a brace or a harness is the spread-squad position. This position is known to force or push the head of the thigh bone (the femur) into the cavity on the pelvis (the acetabulum).

When placed lying on their back, most young babies will pull up their legs in the spread-squat position. And when picked up, the baby will also pull its legs into this position in anticipation of being carried with its front up against the caregiver’s body. If ever there were a natural carrying position designed to promote a healthy development of the hip, the spread-squat position seems a very likely candidate.

This assumption is strengthened when we review some of the medical literature. In recent years, swaddling as a means of calming down colicky babies has gained popularity. Swaddling will in most circumstances force the baby’s legs to be more or less permanently stretched out, with knees kept together. This position has been found to increase the risk of developmental dysplasia of the hip.

Turning to spinal development, some interesting observations have been described by Dr. Evelin Kirkilionis from Freiburg, Germany. She is one of the most recent pioneers in the research of the physiological aspects of baby carrying, working in a small and exclusive research field that goes back several decades.

It is well-known that babies are born with a rounded back, forming a C-shape from the tail to the top of the neck. The typical S-shape of the spine seen in older children and adults develops naturally in the course of the baby’s first year. Chiropractors and orthopedists routinely warn against trying to force the baby’s development by making it engage in activities which it is not developmentally ready for, such as using baby walkers. Such misplaced and premature stress on the young baby’s developing musculoskeletal system can have long-term consequences, affecting spinal health.

The development of the S-curve of the baby’s spine happens in response to the types of movement that the baby will naturally engage in its first year. After several months of life, as the baby begins to raise his head while lying on the floor, the spine starts to take on its secondary curves. The first of these secondary curves is located in the neck and creates a backward C-shaped curve.

The next secondary curve to develop is the low back, or lumbar curve. This curve develops as the baby begins to crawl on all fours. For proper development of the neck curve and lower back curve, the child should be allowed to play on his or her stomach and to crawl as much as they want to.

Dr. Kirkilionis makes an acute observation of any newborn baby placed on its back. If the baby’s legs are forced into a stretched out (extended) position, with knees and feet against the foundation, the baby’s lower back responds by arching, creating a lumbar curvature.

The problem is that this curvature of the lower back is not supposed to be maintained for longer periods until the baby by itself begins to crawl, normally at around 6-7 months of age. And the curvature should develop gradually in response to the baby’s emerging movement patterns.

This leads us to the conclusion that the spread-squat position has merits, not just for the healthy development of the hip, but also for the development of the spine. This holds especially true for the first six months and, likely, also for the ensuing six months where the baby’s spine is gradually responding to the new movement patterns associated with crawling.

Considering the amount of time a baby is likely to spend in a baby carrier, achieving the milestone of locomotion often marks a relative reduction in the amount of time the baby wants to be carried. The baby is enjoying its newly won freedom of movement to explore the world at large, which also coincides with a shift in its primary interests. Put rather oversimplified, the baby is most interested in the human face for the first some six months, and then – with locomotion – switches its interest to objects. However, the child will frequently want to share its interest in objects with the caregiver, practicing what is known as triangulation – the baby tries to make the caregiver share the baby’s attention on the object.

How do these findings relate to carrying the baby facing front-outward?

The first question is whether baby carriers designed for carrying the baby facing front outward (FFO) accommodate the spread-squat position.

A review of existing FFO carriers indicates that very few of them accommodate the spread-squat position. Certainly, all FFO carriers allow for the baby being carried with its front facing inward as well. However, the baby’s leg position is also in this case akin to that of a parachuter, with the legs hanging more or less straight down.

Added to this is the strain of gravity which will tend to pull the baby’s legs downward in the direction away from the hip socket. This is contrary to the spread-squat position which automatically and constantly reinforces the femur’s correct positioning in the hip socket.

And, as noted earlier, one side effect of the stretching out of a young baby’s legs is the premature arching of its lower back in a developmentally delicate phase. If the young baby is then also carried with its front facing outward, this proclivity of arching the lower back is likely to become even more pronounced. This is due to the bodily contours of the person carrying the baby – the stomach of the caregiver pushing against the baby’s back with each breath – and due to the baby’s stomach and chest necessarily pressing against the carrier for support.

Please note that these aspects do not mean that the baby’s skeletal system will necessarily develop abnormally if carried in the FFO position. However, many orthopedists and chiropractors will point to an increased risk, due to the concerns described above.

Indeed, orthopedic text books often point to historic investigations of different tribes or cultures with diverse modes of carrying. Cultures that either swaddle their babies or carry them on a cradleboard, legs extended and adducted (kept together) will have a higher incidence of hip dysplasia, compared to cultures where the legs are kept bent at the hips and spread apart – the spread-squat position.

In a scientific historic sense, the front facing outward — parachute — position is relatively new and untested, compared to the spread-squat position.

Certainly, some babies will be very eager to take in the outside world, often from around 6 months of age. This age also marks the beginning of a new phase where the baby wants to explore the world on its own, so the time spent in a carrier is naturally  reduced.

When carried, if the baby expresses a desire to have a better view of the outside world, it can easily be accommodated by placing the baby on the caregiver’s hip or high up on the back, allowing the baby to see over the caregiver’s shoulder. Carriers exist that allow for such positions. And they keep the baby in that beneficial spread-squat position.

Literature:

Kirkilionis. E. 1997. Die Grundbedürfnisse des Säuglings und deren medizinische Aspekte. Teil 1. Notabene Medici 2, p. 61-66.

Kirkilionis. E. 1997. Die Grundbedürfnisse des Säuglings und deren medizinische Aspekte. Teil 2. Notabene Medici 3, p. 117-121.

Bowen JR & Kotzias-Neto A. 2006. Developmental dysplasia of the hip. Data Trace Publishing Company. ISBN. 1-57400-108-6.

Mahan ST & Kasser JR. 2008. Does swaddling influence developmental dysplasia of the hip? Pediatrics 121;177-178

Salter R. 1968. Etiology, pathogenesis and possible prevention of congenital dislocation of the hip. Can. Med. Assoc. 98; 933-945

International Hip Dysplasia Institute. http://www.hipdysplasia.org/default.aspx

These are very fundamental questions: Should I give ample physical contact to my baby? Or, should I leave it more or less physically separated from me in the hope that this best fosters independence? For many parents, instincts and intuition are sufficient guidelines for their parenting choices. However, such instincts can be challenged by conflicting views, purported by some experts in the field. Some will argue that giving too much physical contact to a baby will make it clingy and dependent in the long run.

One informational resource for such vital decisions comes from the field of science, in this case the science of child development. In a landmark study conducted in 1990, a team of researchers from Columbia University, New York, set out to explore this very question. The study was titled “Does Infant Carrying Promote Attachment?[1]” This study was designed to test the hypothesis that increased physical contact would promote greater maternal responsiveness and more secure attachment between infant and mother. Secure attachment has been found to correlate with autonomy and healthy independence.

The research team was greatly inspired by the work of one of the absolute pioneers in the field of Attachment Theory, Mary D. Ainsworth. In her classic studies, in 1967, in Uganda and the United States, Ainsworth found that the amount of time mothers held their infants was related to the “security-of-attachment rating” that the infants received[2].

Mothers who, in the first months of life, held their infants for relatively long periods, and were tender and affectionate during the holding, had infants who, at 12 months of age, had developed secure relationships with them[3]. In contrast, if mothers were inept in handling their infants and provided them with unpleasant experiences during holding, the infants developed an anxious-ambivalent pattern of attachment.

Several studies have found that mothers of avoidant infants had rejected or sought to minimize physical contact with their infants[4],[5],[6]. Thus, the research team argued, there is evidence that the amount and quality of physical contact between mother and infant is related to security of attachment. By increasing the quantity of physical contact, the experimental treatment of baby carrying may afford the mother opportunities to show affectionate and tender behavior, thus affecting the quality of interaction.

The research team chose mothers from a low socio-economic background as participants for the study. These mothers were expected to have a range of social risk factors, which are likely to affect the quality of the attachment the mothers are able to form with their baby[7]. They would, therefore, also be the mothers most likely to gain from an intervention aimed at improving the attachment quality. If the mothers were already “good enough,” it would be hard to tell the difference – to establish if baby carrying improves the quality of attachment.

After having given normal birth to a healthy child, the mothers were randomly assigned to either an experimental group that received soft baby carriers (more physical contact) or to a control group that received infant seats (less physical contact). The research team took careful precautions to rule out the risk that some mothers might already, prior to the onset of the study, be enthusiastic baby wearers. This could potentially confound the results.

On the day after giving birth, the potential participants were read a list of different baby items and asked whether or not they would use each of the items if it were given to them as a gift. Embedded in the list were a soft baby carrier and an infant seat. Those who had already decided to use a soft carrier or who would not consider using one were eliminated from consideration. The study was explained in detail to those women who indicated that they were willing to use either a soft baby carrier or an infant seat.

In order to obtain an objective estimate of the amount the soft baby carriers were used, pedometers were sewn inside them. Usage questionnaires administered during the test indicated that the mothers used the assigned “tools” frequently.

At 3½ months of age, the babies were filmed during a play session with their mothers. The research team rated the mothers’ ability to respond to their babies’ vocalizations. This was achieved through detailed second-to-second analysis of the observed interactions. The mothers in the experimental (carrying) group were found to be more responsive than control mothers to their babies’ vocalizations.

When the babies were 13 months old, the Ainsworth Strange Situation was administered[3]. This is a test which puts the infant through a series of increasingly (but mildly) stressful incidents, including brief separations from the mother, and being left alone with a stranger in an unfamiliar place. The baby’s specific pattern of response to the separations and reunions correlates to a specific pattern of attachment.

The three patterns analyzed in the current study were the secure attachment, the anxious-avoidant attachment pattern and the anxious-ambivalent pattern. The secure attachment pattern denotes healthy autonomy and independence, accompanied by good social skills. The anxious-avoidant pattern makes the child appear independent, but regrettably with poor social skills and empathy and a latent tendency to display aggression. The anxious-ambivalent pattern results in a typical clingy and dependent child.

The research team found that in the control group 38% of the babies were securely attached, and conversely, 62% insecurely attached. The majority of the insecure attached babies were anxious-avoidantly attached. In the experimental group 83% were securely attached, and only 17% insecurely attached.

The function of having a control group in a scientific study is to inform what the outcome would have been if the intervention of baby carrying had not taken place. Evidently, a very significant change took place in the attachment between mother and child when mothers carried their babies, instead of adopting the more or less standard procedure of less physical contact. The researchers could conclude that when at-risk mothers carried their babies, carrying would indeed “strengthen the bond between mother and child.” Also, the nature of this bond was found to be healthy.

Compared to other types of attachment-related interventions for at-risk mothers, the intervention of providing baby carriers turned out to be extraordinarily effective[8]. The research team speculated on the mechanisms that might be involved in the dramatic change of the mothers’ caregiving skills. Research in monkeys has demonstrated that mothers who have been exposed to maternal neglect in their own childhood tend to be negative towards their offspring, and, also, spontaneously reject physical contact. However, if exposed to sufficient amounts of physical contact with their offspring, their behavior would be modified.[9],[10]

Research conducted in the decades following this study, indicate that the neurohormone oxytocin might be involved in the remarkable effect of baby carrying that the study brought to light. Please refer to our previous Ergoparent article, “Oxytocin and Your Baby,” for a brief review.

Some mothers have not had the most rewarding childhood or have been struggling with a difficult pregnancy and birth, perhaps combined with economic worries, high pressures of work or a fragile marriage. All these factors are known to put the strength and quality of the bond to one’s child at risk.

Luckily, it does seem that the intuition that baby carrying will strengthen that vital bond has been borne out by this careful study.

[1] Anisfeld E, Casper V, Nozyce M, Cunningham N. Does infant carrying promote attachment? An experimental study of the effects of increased physical contact on the development of attachment. Child Dev 1990;61:1617–1627

[2] Ainsworth, M. D. S. (1967). Infancy in Uganda: Infant care and the growth of love. Baltimore: Johns Hopkins University Press.

[3] Mary D. Salter Ainsworth, MDS, Blehar MC, Waters E. & Wall S. Patterns of Attachment. A Psychological Study of the Strange Situation. Lawrence Earlbaum Associates. 1978 Hillsdale, New Jersey

[4] Egeland, B., & Farber, E. A. (1984). Infant-mother attachment: Factors related to its development and changes over time. Child Development, 55, 753-771.

[5] Main, M. (1977). Analysis of a peculiar form of reunion behavior seen in some day-care children: Its history and sequelae in children who are home-reared. In R. A. Webb (Ed.), Social development in childhood: Day-care programs and research (pp. 33—78). Baltimore: Johns Hopkins University Press.

[6] Main, M., & Stadtman, J. (1981). Infant response to rejection of physical contact by the mother. American Academy of Child Psychiatry, 20, 292-307.

[7] Spieker, S. J., & Booth, G. L. (1988). Maternal antecedents of attachment quality. In J. Belsky & T. Nezworski (Eds.), Clinical implications of attachment (pp. 95-135). Hillsdale, NJ: Erlbaum.

[8] Juffer F, Bakermans-Kranenburg MJ & Van Ijzendoorn MH. Promoting Positive Parenting. P. 74. Lawrence Earlbaum Associates. 2008. ISBN 0-8058-6352-4

[9] Harlow, H. F., & Suomi, S. J. (1971). Social recovery by isolation-reared monkeys. Proceedings of the National Academy of Sciences, 68, 1534-1538.

[10] Suomi, S. J. (1973). Surrogate rehabilitation of monkeys reared in total social isolation. Journal of Child Psychology 6- Psychiatry, 14, 71-77.

It is thus no surprise that bouts of inconsolable crying will stress most parents, as with babies suffering from what is commonly known as colic. Here the baby is clearly signaling that something is bothering her or him, yet the parent or caregiver is not able to find the root cause of the incessant crying and help the baby calm down.

In this article, we will learn about crying and colic in babies and examine some of the hypotheses, and the resultant interventions offered for its resolution. We will scrutinize the scientific studies on how carrying may or may not affect crying and colic.

Interested parents will thereby become able to interpret their children’s cry signals in an appropriate manner. Such an understanding will moderate the parents’ perception of what is taking place in the baby and also lead to a more informed reflection of their own caregiving capabilities, in the face of an incessantly crying and inconsolable baby.

Basic definitions and patterns

Let us begin with making sure that we have the basic understanding in place. Researchers studying crying operate with different basic concepts. The baby’s “cry pattern” denotes the timing of the crying over a 24-hour cycle. The baby’s “cry quantity” describes the amount of crying over a 24-hour cycle.

Colic is defined by “the rule of three” as 3 hours of crying and fussing for a minimum of 3 days a week (and some researchers add: for a minimum of 3 weeks).

Amongst 0 to 12-week-old Western babies, recent research into crying has established the following general patterns:

1. Babies cry the most in their first three months. The average cry quantity, including fussing, amounts to an average of approximately two hours per day.
2. Babies’ cry quantity will increase from birth until it peaks at the age of six weeks, whereafter it tapers off until twelve weeks, when it is halved relative to the peak.
3. There is a great variety in the cry quantity amongst babies. Some babies (approximately 5-19%) will cry and fuss for three hours or more per day and will thus be considered “colicky babies.” Others will cry very little.
4. Babies’ crying pattern follows a diurnal rhythm. Babies will cry the most in the evenings, which also goes for the babies who cry very little.
5. Child number two will cry as much as the firstborn. Not surprisingly, parents of firstborns tend to seek assistance from the child health care system more frequently.
6. There is no difference in the amount of crying between girls and boys.
7. Approximately 40% of all babies will experience inconsolable bouts of crying and fussing at age ten days old. The same percentage applies at age five weeks. This however, does not mean that they are colicky, which requires that they meet the criteria of “the rule of three.”

A minimum requirement for an ergonomically correct position is that it should ideally promote a healthy development of the baby’s hips and spine.

One of the conditions which pediatricians will normally investigate in a newborn child and in subsequent well-baby check-ups is that of developmental dysplasia of the hips (DDH).

Hip Dysplasia definition and occurrence

DDH is a disorder related to what is commonly known as the hip joint. The hip joint is where the head of the thigh bone (the femur) meets with the hip socket (the acetabulum). Hip dysplasia is diagnosed when there is either a complete or partial dislocation of the head of the thigh bone, so it no longer fits snugly and firmly into the hip socket; or instability, as when the head of the thigh bone comes in and out of the socket.

Doctors tend to stress the term developmental dysplasia of the hip, as the above conditions may not be present at birth. The earlier a dislocated hip is detected, the simpler and more effective is the treatment. Despite newborn screening programs, dislocated hips continue to be diagnosed later in infancy and childhood, in some instances delaying appropriate therapy with resultant quite significant encumbrances to the affected child and parents.

Hip Dysplasia at birth is not a very common condition, around 1.4% is affected, and approximately 1% of all infants are evaluated or treated for the condition. Estimates of the incidence tend to vary quite significantly, depending on when and which type of examination is performed. Universal ultrasound screening has determined that as many as 7-10% of all newborn infants have hip instability shortly after birth. Curiously, it is most prevalent amongst first born girls, about 8 times more common than amongst boys. Some of the known risk factors for hip dysplasia include being born into a family with a history of hip dysplasia, and being born in the breech position (being born entering the birth canal with feet or buttocks first). In breech babies, the frequency of hip dysplasia varies from 5-25% and approaches the lower number when C-section is the method of delivery. This means that mechanical forces during birth may increase the risk of hip dislocation or hip dysplasia.

Interestingly, swaddling – with the baby’s legs are stretched out and kept together – has also been established as a risk factor for DDH. This is a greater risk factor than family history or breech birth. This position tends to pull the thigh bone head out of the hip socket. So if one adopts the practice of swaddling, one should make sure  that the legs are spread apart.

DDH certainly is no trivial condition. If not caught and treated correctly, there is a very real possibility of a limp, constant and/or debilitating pain, complicated treatment and impaired mobility later in life. Undetected hip dysplasia causes approximately 10% of all total hip surgeries performed in the USA and it is the most common cause of hip arthritis in young women.

Babies in the breech position are more likely to have hip instability than babies in a normal womb position.

What may cause hip dysplasia?

The etiology – that is, the cause of DDH – was previously understood to be primarily a congenital condition, whereby the thigh bone head for mysterious reasons was not able to latch on to the hip socket. Currently, DDH is thought to arise in part because of a premature “unfolding” of the baby. During the baby’s time in the uterus, the legs will naturally be completely bent at the hip and also be spread apart. At the time of birth, the thigh bone head consists largely of cartilage, which gradually turns into bone.

However, the degree to which the cartilage has turned into bone at the time of birth can vary quite substantially, resulting in different levels of susceptibility to DDH. To ensure a proper forming and continuous placement of the thigh head bone in the hip socket during the ossification (bone formation) process, the legs should not be stretched out for too long a period of time. They should instead be kept bent in an adapted position which maintains some similarities to that of the position while in the uterus.

The medical treatment of DDH in the first year will normally include placing the child in a “Pavlik harness.”  The position in which the harness keeps the baby is also more commonly known as the frog position.

Baby carrying and hip dysplasia

Some prominent orthopedists, such as the German orthopedist, Dr. Fettweis advocate baby carrying in a good ergonomic carrier as a way of preventing DDH. However, it is vital that the carrier supports the baby’s legs in such a way that the baby is held in the frog position, legs apart, knees pulled up a little higher than the hip joint.

One of the advantages stressed by orthopedists is the movement that the carrying adult will confer upon the baby and especially the baby’s legs and hip joints. The baby will respond with contractions of the relevant thigh muscles, hence providing exercise to the muscles while at the same time having the thigh bone head constantly pushed correctly into the socket, reinforcing the proper positioning in a natural and unstrained way . The movement and the muscular activity will also stimulate the blood flow, which in turn will also speed up the process of turning the cartilage into bone.

When the baby is placed in a harness, there will naturally be less of this type of movement, as the baby will be fixated in the position, unless a special physical therapy is included in the treatment of DDH. Nevertheless, it seems that no scientific investigations have been conducted this far on whether proper ergonomic carrying might be as effective (or more) as placing the baby in a harness.

Carrying one’s baby can be done for many reasons. It is certainly good to know that it will, on top of the many other benefits, also help the baby develop healthy hip joints.

Resources:

Guille JT, Pizzutillo PD, MacEwen GD. Developmental Dysplasia of the Hip From Birth to Six Months.  J. Am. Acad. Ortho. Surg., July/August 2000; 8: 232 – 242.

Vitale MG and Skaggs DL. Developmental Dysplasia of the Hip From Six Months to Four Years of Age. J. Am. Acad. Ortho. Surg., November/December 2001; 9: 401 – 411.

Lehmann, HP, Hinton R, Morello P, Santoli J in conjunction with the Committee on Quality Improvement and Subcommittee on Developmental Dysplasia of the Hip. Developmental Dysplasia of the Hip Practice Guideline: Technical Report. Pediatrics 2000;105;e57

E. Fettweis. Über das Tragen von Babys und Kleinkindern in Tüchern oder Tragehilfen. Orthopädische Praxis 46, 2, 2010 (In German)

Evelin Kirkilionis. Ein Baby will getragen sein. Alles über geeignete Tragehilfen und die Vorteile des Tragens. Kosel. (In German)

Let us begin with examining the concept of co-sleeping – what exactly is meant by this term? Co-sleeping refers to the many different ways a baby sleeps in close emotional and physical contact with their parents, usually within arm’s reach. Co-sleeping thus implies that the baby and parent can be bed-sharing, i.e., sleep in the same bed on the same surface. The baby can also be placed on a separate surface, as in a bassinet, which is attached to the parents’ bed and also has an open side towards the parents’ bed for easy contact. A third approach is to have the baby sleep in the same room, but in a separate crib or bassinet.

Incidentally, in part because of the controversy surrounding co-sleeping, the practice has been investigated thoroughly by researchers over the past three decades, and we now have a good overview of the benefits and risks associated with co-sleeping. Conversely, we also know the risks associated with NOT co-sleeping.

Babies’ benefits of co-sleeping

Babies’ benefits of co-sleeping listed by the researchers include the following:

The baby receives continual reminders of caregivers’ presence – touches, smell, movement, warmth and taste (from nightly breast feedings) and is thus reassured.

In case of a threat to the baby’s wellbeing (if the baby is e.g., choking), a light sleeping mother will be able to help right away.

Babies co-sleeping tend to cry less or not at all, resulting in lower levels of stress hormones.

Babies are warmer when sleeping next to their mothers – lower temperatures can reduce immunity, making baby more susceptible to infectious diseases and divert energy away from growth and development.

If the baby is breastfed and co-sleeping, the researchers have found the following benefits in addition to the above:

Babies who sleep with their mothers and breastfeed spend less time in the deepest  stages of sleep. Light stage sleep is thought to be physiologically more appropriate and safer for babies, because it is easier to awaken to terminate apneas (episodes where one stops breathing), than it is when babies are in deeper stages of sleep. The mother’s movements and the smells of mother’s breast milk nearby both contribute to the baby remaining in lighter sleep for longer periods of time.

The babies stimulate their mothers’ milk supply by breastfeeding during the night. The breast feedings are also more frequent and longer, which means greater weight gain.

Babies and mothers have a heightened and enhanced sensitivity to each other’s smells, movements and touches.

Parents’ benefits

There are benefits for the parents, too.

It is not unusual that parents will initiate co-sleeping when their baby is found to have sleep disturbances, prompting the parents to have to get up and out of bed several times per night. In the end, they often realize that they will get better and more sleep, if they simply co-sleep with their baby. With the baby so close, the mother can breastfeed while half-asleep, rather than having to wake up and go to another room to tend to a crying baby

Co-sleeping is often found to enhance the whole breastfeeding experience for the mother, with mothers maintaining breastfeeding for a longer duration, compared to non   co-sleeping parents.

Working parents also report how greatly they appreciate the contact with the baby that co-sleeping allows, which makes up for the lack of contact during day hours. “Peaceful,” “comforting,” “loving” and “protective” are words that show up repeatedly when parents state their reasons for co-sleeping. Some researchers point to the effects  of oxytocin and the skin-to-skin contact that many parents will have with their baby when co-sleeping, resulting in lower stress levels in the parents and baby alike.

Risks associated with co-sleeping

Turning to the risks of co-sleeping, much of the controversy surrounding co-sleeping is really about the risks associated with bed-sharing. Here the parent(s) and the baby share the same bed. Interestingly, even the conservative and risk-averse American Academy of Pediatrics (AAP) in their Sudden Infant Death Syndrome (SIDS) policy statement of 2005 does in fact recommend co-sleeping in the shape of a separate but proximate sleeping environment. The Academy recommends co-sleeping as the risk of SIDS has been shown to be reduced when the infant sleeps in the same room as the mother.

Advocates of the baby sleeping in a separate room should thus be aware that AAP has found that this practice has a higher risk of SIDS associated with it, relative to a co-sleeping arrangement.

AAP in their policy statement also refers to “co-sleepers” (infant beds that attach to the   mother’s bed) and how they provide easy access for the mother to the infant, especially for breastfeeding. AAP however indicates that safety standards for these devices have not yet been established by the Consumer Product Safety Commission.

Risks associated with bed-sharing

As regards the position of AAP on bed sharing, their view is that “bed-sharing, as practiced in the United States and in other Western countries, is more hazardous than the infant sleeping on a separate sleep surface” and therefore recommends against it.

Researchers who have scrutinized bed-sharing over the past several decades in dedicated sleep-laboratories find this recommendation to be too general and imbalanced. There certainly are risk factors that should be taken into consideration when bed-sharing, but if heeded, the researchers find that bed-sharing is a safe and recommendable practice.

The risk factors for bed-sharing include the following: Obese parents; parents who smoke (either during pregnancy or at present); parents sleeping on a waterbed, recliner, sofa, armchair, couch or bean bag; parents who sleep on multiple pillows, a sagging mattress or a sheepskin or use heavy bedding, such as comforters or duvets; sleeping in overheated rooms; parents under the influence of drugs or alcohol; other children or pets who can or are likely to climb into the bed; and stuffed animals on the bed that could cover the baby’s face.

Also, if routinely bed-sharing, it is ideal to pull your bed away from the walls and surrounding furniture into the center of the room, strip away metal or wood framework and lay the box spring on the floor with the mattress on top.

Data from Consumer Product Safety Commission indicate that the greatest risks to a baby sleeping in a bed with an adult is not, as many would assume, from an adult overlaying or rolling over onto the baby, but from the infant strangling or becoming wedged or trapped between a wall, a piece of furniture, the bed frame, headboard or footboard and the mattress.

Will co-sleeping affect my child’s development?

Some pediatrics have voiced concerns that co-sleeping will hinder the development of the child’s independence. One study has found that, compared with solitary sleepers from birth, infants who co-sleep from birth, either learn or accept sleeping alone about a year later than infants who have no choice but to sleep alone. On the other hand, you as a parent will not have had the great feelings and memories from co-sleeping with your baby, if you let your baby sleep in a separate room.

Parents wanting to end their co-sleeping with their baby ought to be much helped by the gradual approach described by Elizabeth Pantley in her book “The No-cry Sleep Solution.”

Overall, there certainly is no reason for concern for your child’s capability of independence. Various studies indicate that co-sleeping infants develop more permanent capacity for self-sufficiency, resilience, comfort with affection and the ability to be alone when necessary.

Naptimes

Most babies do not mind sleeping alone during daytime naps. However, contrary to advice, the idea of “sshhhhh – the baby is sleeping” only conditions the baby to sleep lightly and to stir at each extraneous noise. So feel free to place the baby’s  bassinet in a room where there are active and vocal people (including children) around.

The impact of co-sleeping on parents’ relationship

One of the questions often raised in relation to co-sleeping is how will it affect the parents’ relationship. The short answer to that is that all families are unique, so it is hard to say with any degree of certainty how it will affect your relationship. Fathers often find co-sleeping to be emotionally rewarding, especially if they are separated from the baby during daytime which is the case for most fathers. And co-sleeping does not have to affect tenderness and closeness between spouses – talk, touch, massage and laughing with a sleeping baby present are certainly feasible.

Maintaining intimacy will require a little more creativity, but again here parents find their own ways that are compatible to their circumstances and values.

In the end, sleeping arrangements are a very personal choice, with many aspects to consider, but at the very least, parents should not be made to feel guilty for choosing to co-sleep, as indeed this practice does confer a range of benefits on both parents and baby, if carried out conscientiously and responsibly.

Happy sleeping!

Resources:

Books:
James J. McKenna. Sleeping with your Baby. Platypus Media 2^nd edition 2009.

Maria Goodavage and Jay Gordon. Good nights: the Happy Parents’ Guide to the Family Bed. ISBN: 312275188

Elizabeth Pantley. “The No-cry Sleep Solution”. McGraw-Hill 2002.

William Sears. Nighttime Parenting: How to Get Your Baby and Child to Sleep. ISBN: 452281482

DVD:
Helen Ball, Sally Inch and Marion Copeland. The Benefits of Bedsharing. DVD. Platypus Media. 2005.

Links:
www.usbreastfeeding.org

www.lalecheleague.org

www.ilca.org

The fundamental ideas of API stem from the pioneering work of Sir John Bowlby who formulated the concept of Attachment Theory. His work has subsequently inspired hundreds of researchers across the globe. They have strived to refine the concepts to make them even more applicable for parents and to assist early care workers in their efforts to help babies and children who have not had initially good circumstances.

In this article we will take a look at the founder of Attachment Theory, Sir John Bowlby – his time, what inspired him and his fundamental concepts. And what questions we should ask ourselves in our day and time.

This journey will take us to a time where children had little contact with parents, where children’s reactions to being separated from their parents would be dismissed as psychopathological fantasies and where a child was thought to need no more than food and shelter. Sadly, fragments of these misconceptions of bygone days still linger among us, which makes the work of API so important.

But let us begin with looking at Bowlby’s life and how he was formed by his experiences.

Bowlby’s life and career

Sir John Bowlby (1907-1990) was born into an upper middle class family in England, where his father worked as a surgeon to the King’s Household. As customary at that time, he saw his mother only one hour a day after teatime, though during the summer she was more available. Like many other mothers of her social class, she considered that parental attention and affection would lead to dangerous spoiling of the children. Bowlby was lucky in that the nanny in his family was present throughout his childhood. When Bowlby was almost four years old, his beloved nanny, who was actually his primary caretaker in his early years, left the family. Later, he was to describe this as tragic as the loss of a mother.

He was also sent to a boarding school at the age of seven, and later revealed that he thought this time as being terrible. Because of these experiences, he displayed sensitivity for children’s sufferings throughout his life.

He went on to study psychology at Cambridge, where he also had a six month stint with teaching maladjusted and delinquent children. Here he was touched by how some of these children would avoid attaching themselves to anyone. At the same time, he experienced that he was able to make contact with the children, which inspired him to train as a child psychiatrist and psychoanalyst.

Working for a period, prior to World War II, at the Child Guidance Clinic in London he noticed how the childhood experiences of parents influenced the difficulties that their own children were having. And that many of these difficulties would be relieved, if the parents were allowed to discuss and reflect on their own childhood experiences.

After the war, in 1946, he became the leader of the children’s department at the Tavistock Clinic in London where he worked until his retirement in 1972. In this capacity, he organized a research unit whose main task was to investigate the effects of separation of mother and child and also to elucidate which aspects of the mother-child interactions and relation were vital for the development of the individual personality.

After World War II which led to millions of children becoming orphans he authored a monograph on behalf of the World Health Organization in 1951 which summarized the – sparse – available knowledge on the negative effects of the absence of maternal care on the development of the individual personality. In the course of his writing, it became apparent to him that a coherent theory for the effects that were so visible in the real world was sorely missing. This propelled him to eventually begin formulating the concepts of Attachment Theory, which he elaborated on until his death in 1990.

The fundamental concepts of Attachment Theory

Food or comfort?

At the time Bowlby grappled with formulating his concepts, the baby was thought to seek out the mother, primarily for the reason that she was the supplier of food. So if the mother did not supply food, the baby would not form any specific ties to her. The baby’s primary need and source of attaching to anyone, in this angle, would be that of food. And because of this need, the baby would be dependent on the mother/feeder. Dependency was thus considered an infantile trait that should be outgrown eventually.

Bowlby however found that it was not the mother as a feeder, but the mother as a communicating, protective and empathetic figure that gave rise to an attachment of a given baby. In this perspective, the baby would be an inherently or intrinsically social being with a need to communicate and to form emotional relations to an adult.

This distinction may seem trivial, but it was crucial in the way it shaped society’s perception of what constituted sufficiently good child care. If food (and shelter) is indeed the primary need of a baby, then an orphaned baby or even a baby with its parents ought to be satisfied when it is no longer hungry, and no attempts should be made to communicate or form ties to the child, as it would only strengthen the baby’s dependency on the parents or the caregiver.

Dependency…

The concept of dependency which should necessarily and unyieldingly over time lead to gradually greater independence was another concept, which Bowlby found was inadequate to explain the behavior of children. What if a four year old, during a period of elevated stress, were to seek out the parents and need considerably more attention and closeness than normally? Should this behavior be considered a regression of the four year old to a more infantile stage of dependency (which should have been completed long ago) and the child therefore be rejected so as to not encourage the child to remain in its infantile and regressed state? Yes, was the common answer at the time. Sadly, this view still informs the practice and approach of some parents when dealing with stressed children.

Attachment and exploration

Bowlby over time developed a more flexible concept, whereby the baby from around 7-8 months would form a selective attachment to a specific caregiver. This caregiver would be whichever person who more or less consistently provided physical and emotional security to the baby. The baby would use this attachment figure – the caregiver – as a secure base in its discovery of the surrounding world, much in the same way an Arctic expedition team will make excursions out in the local unpredictable and occasionally precarious environment and return to the base camp for rest and recreation.

When the baby faced incomprehensible or threatening situations in its exploration of the environment, it would activate its attachment behaviors, be it crying, shouting or crawling back to the attachment figure. Attachment behavior is designed to attract the attention of the caregiver and to bring about greater physical closeness to the caregiver, which in the baby’s mind equals security.

So the two behaviors of exploration and attachment respectively would wax and vane, depending on the baby’s perception of the environment. If the environment seemed safe, and the caregiver was physically present, the baby would set out to explore the environment and the attachment behavior would be deactivated. When then a perceived threat appeared, the attachment system would become activated and the active exploration of the environment would be temporarily suspended.

Viewed from this perspective, it would be utterly natural and expected that any baby will occasionally need the attention, comfort and solace of a caregiver, and bids for comfort from the baby should naturally be heeded and met. A radically different position to the one outlined above where the baby was considered to be regressing when needing the caregiver.

Internal Working Models

Exactly this very way that the individual caregiver responds to the baby’s bids for comfort would in Bowlby’s perspective be what ultimately shaped the baby’s perception of the nature of relations to other people. He dubbed this mechanism “internal working model”.

This “internal working model” arises as a result of the baby’s own activities and experiences with the real environment and its caregiver(s), and is not, as some psychoanalysts insisted at that time, based on fantasies. The baby will use its working model to predict what to expect from the outside world and the working model thus also influences the baby’s intentions and behaviors.  And what is even more crucial, the working model shapes the baby’s perception of itself as being e.g. pleasant, fun and worthwhile to be with, or a general nuisance which is fundamentally in the way, all depending on the way, the caregivers/parents deal with the baby.

Patterns of Attachment

This concept of an “internal working model” was later validated by one of his students, Mary Ainsworth, who found that babies at 12 months would display very specific patterns of attachment which were directly related to the quality of caregiving that they had been exposed to in the preceding months. Please refer to Antje Hein’s article in this month’s issue of Ergoparent for more details on these patterns of attachment.

Subsequently, researchers have followed groups of children, whose patterns of attachment were established at age 12 months, through their childhood and early adulthood. These patterns of attachment were found to form a trajectory or a general style of the individual child in how this child, and later, adult, would meet the world and form relations to others. If a child was found to be insecurely attached at 12 months, the odds were that this pattern would persist throughout childhood and adulthood, to the detriment of the child – and its surroundings.

However, one word of caution, attachment status at 12 months does not equal unyielding fate. The nature of the human soul is so that it will doggedly try to resolve past negative experiences and their resultant disadvantageous relationship patterns. Some are fortunate to run into people who in various and sometimes mysterious ways help them overcome the past so that they become able to form healthy and constructive relations, despite all prior obstacles.

Nevertheless, Bowlby pointed out some fundamental mechanisms between a baby and its caregivers/parents and thereby initiated a much needed adjustment of parenting practices, and we are still indebted by his tireless and deep commitment to creating good and mentally healthy conditions for our children.

What are the blind spots of our time?

In hindsight, we may be shuddering at the views and ways of our grandparents’ time, which to us now seem insensitive and callous, but rather than riding on a moral high horse, we might do well in asking ourselves what are the challenges that we face in our time.

The ubiquitous synthetic chemicals that we voluntarily surround us with – and which seem to affect fundamental biological systems relating to immunity and reproduction – could be one such challenge. And perhaps we are still underestimating how closely connected we are to our evolutionary ancestors when it comes to providing vital skin to skin contact in the baby’s formative months. In the past few years, science certainly has been uncovering hitherto unknown relations of mammalian hormonal systems (which date back millions of years) to the quality of parenting and the baby’s development.

Many parents have certainly come a long way, but far too many across the globe are still struggling and the quest for securing a healthy childhood for all has really only just begun. Organizations like Attachment Parenting International and researchers like John Bowlby are indispensable in this quest and they deserve our respect and support.

Over and above being a mutually pleasurable activity, research into infant massage over the past decades has established a range of beneficial effects on the infant, and equally important, on the relationship between the mother and her baby. In this article, we will look at some of the effects of infant massage on premature and full-term babies, respectively. These effects include weight gain, sleep organization and mother-baby relationship.

Infant massage for premature infants

Extensive research has been conducted on the effects of infant massage on stable pre-term infants. Certainly, premature birth is no trivial matter. At present approximately 14% of infants in the United States are born prematurely, according to The National Center for Health Statistics. Prematurity, in turn, is one of the leading causes of infant morbidity and mortality, and it results in approximately 15.5 billion dollars in hospital costs per year.

Following intensive care treatment, weight gain becomes the main criterion for hospital discharge. Thus, several interventions have been designed to promote preterm infant weight gain, including massage therapy.

Several independent, randomized, controlled studies confirm the efficacy of infant massage in promoting weight gain in premature babies, leading to earlier discharge from the hospital.

The infant massage protocol, in studies on the effects of massage therapy on neonatal intensive care unit preterm infants, involves moderate pressure stroking (tactile stimulation) and flexion and extension of arms and legs (kinesthetic stimulation). These sessions have varied between 10 and 15 minutes and have been held two to three times a day for 5 to 10 days.

Mothers as massage therapists

The question occasionally arises whether infant massage can be done by mothers or if professional physiotherapy is required to achieve these desired increases in weight gain.

An elegant study investigated this issue by assigning preterm infants to three groups. These three groups included one treatment group in which the mothers performed the massage, and another, in which professionals unrelated to the infant administered the treatment. These two groups were then compared to a control group. Over the 10-day study period, the two treatment groups gained significantly more weight compared to the control group suggesting that mothers were able to achieve the same effect as that of trained professionals.

Maternal depression

Benefits on the infant massage were not just observed for the babies involved. Interestingly, the mothers who massaged their infants in one study experienced a decrease in depression symptoms, which are often seen in mothers of preterm infants. In another study using mothers as the massage therapists, even one session was effective in lowering both the mothers’ depression and anxiety symptoms.

Moderate pressure is critical

The question of whether light or moderate pressure in the massage therapy is most effective in promoting weight gain has also been addressed in several studies. The evidence to hand suggests that moderate pressure is most optimum. Moderate pressure massage has also been shown to reduce stress behaviors in the massaged infants, compared to the control group.

Infant massage for full-term babies

Weight gain

The effects of infant massage on the baby’s weight gain are not just seen in premature babies.

In one study, parents delivered the massage to their full-term newborns from day one to the end of the first month. Those infants gained more weight and gained more length, as well as performed better on the thoroughly validated “Brazelton Neonatal Behavior Assessment Scale,” by the end of the month that the parents provided the massage.

The parents involved were taught by massage therapists in infant massage classes whereupon the parents could continue the massages at home.

Sleep organization

Other studies have looked at another crucial element of a baby’s sound development – the baby’s sleep organization, or sleep patterns. Certainly, any parent of a baby suffering from sleep disturbances will appreciate practices which will help reduce this phenomenon.

One study sought to examine the effects of infant massage therapy on the baby’s ability to gradually adjust its phases of rest and activity in such a way that these phases align better with day and night – and thus the timing of the parents’ phases of rest and activity. The study also investigated the adjustment of the rhythm of the excretion of sleep hormone melatonin.

Starting at the age of approximately ten days old, the babies were given 14 days of infant massage therapy. The babies’ cycles of rest-activity were measured both before and after the 14-day massage therapy, and, subsequently, at six and eight weeks.

At eight weeks, the non-massaged control group babies revealed one peak of activity at approximately 12 midnight and another one at approximately 12 noon. Hardly the ideal timing of activity for parents who are trying to get a good night’s sleep to cope with the challenges of life with a newborn….

For the massaged group of babies, at eight weeks, a major peak of activity was early in the morning and a secondary peak in the late afternoon. This is certainly a more accommodating rhythm of baby activity levels for most parents, especially when one or both parents are working.

When the researchers looked into the so-called circadian rhythm (which regulates sleep and wake phases), via measurements of the hormone correlated to the circadian rhythm, melatonin, they found the following:

At 12 weeks, the nightly urinary excretions of melatonin were significantly higher – about 64%  – in the massaged babies, compared to the non-massage control group of babies. This result suggests that the massaged babies had adjusted their circadian rhythm better to life outside the womb, with its alternations between day and night. The massage therapy by mothers in the perinatal period seems to serve as a strong time cue, enhancing coordination of the developing circadian system with environmental cues, such as light, noise and activities of the caregivers.

Effects of infant massage on babies’ sleep patterns have been found in several other studies.

Mother-baby relationship

Infant massage differs from some of the other activities that parents will engage in with their baby, such as feeding, changing diapers, transporting, etc., in that there is no direct instrumental purpose in the activity of infant massage, other than that of imparting pleasure and relaxation to the baby.

In a study conducted in the UK, parents emphasized the benefits of massage on relaxation and bonding, an activity essential to the early stages of the developing relationship between a baby and its parents. Infant massage was a way of creating a special and enjoyable time together with their baby. It was also a way of learning about their baby, appreciating how responsive the baby could be to them as a parent, and learning to recognize and understand their baby’s communication to them. The parents highlighted how the activity of infant massage improved their relationship with their baby and made their baby happy and content.

A randomized, controlled study investigated the effect of infant massage on the mothers’ perception of their babies’ temperament.

When the babies were 12 months old, the mothers were asked to evaluate their babies’ temperament. Interestingly, the mothers in the infant massage group rated their babies as having a less difficult temperament than mothers of the control group. The infant massage mothers were more confident of their skills. They were also able to relate better with the baby and qualified it more positively than mothers in the control group.

A baby’s temperament is considered to result from the interaction between the baby’s genetic heritage, its environment, and social interactions. Within the environmental factors, the sensitivity of parental involvement and adequate responses from parents is an important element. The study suggests that mothers who learn how to perform infant massage have more positive attitudes towards motherhood and stronger capability to cope with the baby’s temperament.

Apart from the sheer fun of giving infant massage, there are plenty of good scientifically supported reasons to engage in it. And to boot, mothers have intuitively been doing it for millennia across the globe, notably in the Far East and South East Asia, so you are taking part in a long continued tradition.

Enjoy!

Selected literature:

Field T., Diego, M. & Hernandez-Reif, M. Preterm Infant Massage Therapy Research: A Review. Infant Behav Dev. 2010 April ; 33(2): 115–124.

Ferber S.G., Laudon M., Kuint J., Weller A. & Zisapel N. Massage therapy by mothers enhances the adjustment of circadian rhythms to the nocturnal period in full-term infants. J Dev Behav Pediatr. 2002 Dec;23(6):410-5.

Clarke, C.L., Gibb, C., Hart, J. & Davidson, A. Infant massage: developing an evidence base for health-visiting practice. Clinical Effectiveness in Nursing 2002 6, 121–128

Bárcia, S.¹ & Veríssimo, M.² The relationship between infant temperament and infant massage. Affiliation: ¹UIPCDE, ISPA & Universidade Atlântica, ²UIPCDE, ISPA, Portugal. Poster exhibit at World Association of Infant Mental Health biennial conference, Leipzig, 2010.

On-line resources:

Touch Research Institute
http://www6.miami.edu/touch-research/
http://www6.miami.edu/touch-research/Touchpoints%20Summer%202010.pdf

The International Association of Infant Massage
http://www.iaim.net/

Infant Massage USA
http://www.infantmassageusa.org/

The Guild of Infant and Child Massage (United Kingdom)
http://www.gicm.org.uk/

International Association of Infant UK Chapter
http://www.iaim.org.uk/

The first recourse is naturally to make sure that the basics are in place. There is plenty of literature out there, which an expectant woman can read at her own leisure. The website of La Leche League is a very good on-line source of information. La Leche League has also published a good and thorough book “The Womanly Art of Breastfeeding.” However, if the baby is already there, and the mother feels overwhelmed by the many demands of the little one, calling on a lactation consultant could be a wise measure.

The basics of breastfeeding include finding a proper position that suits you and your baby, so you both can relax. This may involve some experimenting, including propping yourself and your baby up with pillows.

The proper latching on of the baby to the mother’s breast is of fundamental importance and can make all the difference in the world, not least when breastfeeding is experienced as painful.

Being aware that the composition of the milk changes during each feeding helps too. The milk will change from being relatively light to become richer in fat during each feeding. The first part of the feeding serves to quench the baby’s thirst, the latter part to satisfy her or his hunger. Ending off a feeding prematurely will force the baby to demand more frequent feedings and thus less breaks for the mother.
Ending off the feeding prematurely can also lead to sore breasts and, eventually, also inflammations of the breast. When the milk is made to stagnate it can mess up the finely tuned system.

Having adopted all these fundamentals, and even after enlisting the help of a professional lactation consultant, some women, however, still experience either intermittent or persistent pain associated with breastfeeding. Some women experience brief periods where the breastfeeding lives up the pleasant expectations, interrupted by periods where breastfeeding is again painful and a source of frustration.
It is like a pendulum swing, going back and forth. For some women, having exhausted the sources of help and external advice, the pain and frustration becomes unbearable and breastfeeding becomes more of a threat to the bond of love and pleasure that any mother hopes to form with her baby. They then make the decision to switch to formula milk; a decision that should be respected.

For some mothers the pain is sufficiently bearable for them to persist in breastfeeding and most will report that after a period ranging from a few weeks to several months, breastfeeding becomes the smooth and mutually pleasant bonding experience which they were hoping for.
The scientific literature on breastfeeding offers relatively little direct insight into the possible mechanisms underlying these large variations in the breastfeeding experience.

However, one candidate mechanism seems to involve the birth and breastfeeding hormone oxytocin. Oxytocin is the hormone that causes the uterus to contract during labor and birth. It is also responsible for the milk let-down mechanism by making the muscle cells surrounding the breast’s milk producing glands contract.

These are the classical and well-known effects of oxytocin, however, research in the past two decades has shed light on some highly interesting and relevant effects of oxytocin.

The level of oxytocin in the body seems to correlate inversely with the level of stress hormones, heart rate and blood pressure. The more oxytocin you have flowing around in your body, the less stressed you are likely to be. And we know that stress is very counterproductive to breastfeeding. Oxytocin also seems to work as pain reducer. So, the more oxytocin you have in your body, the greater your tolerance will be towards pain.

What is even more interesting is the correlation between levels of oxytocin in the parent’s blood and saliva and the quality of parenting that they are able to provide. High oxytocin parents seem to be more in tune with their babies and they derive more pleasure from their interactions with their baby, which then turns into a virtuous circle. Interactions with the baby are simple, straightforward, uncomplicated and fun.

What the researchers have recently established is that in any given group of human parents, there will be variations in the naturally occurring levels of oxytocin in their blood and in their saliva. Some parents will, for reasons as of yet unknown, have high levels of oxytocin, others will have low levels.

The good news is that there is circumstantial evidence that it is possible to influence the levels of oxytocin in a human body. One tried and tested approach to difficulties with initializing breastfeeding is to have the mother engage in skin-to-skin contact over a period of several days. This will normally cause the oxytocin level to increase and thus stimulate the milk let-down reflex.

In one study, the researchers examined the effects of prolonging the period where the mother involved herself in skin-to-skin contact with the baby. During the first week the mother would engage in skin-to-skin contact for approximately five hours a day, and in weeks two through five, two and a half hours a day. Interestingly, of the women who initiated breastfeeding after birth, the amount of breastfeeding women in the skin-to-skin contact group remained the same after three months, presumably meaning that not one single skin-to-skin mother had ceased breastfeeding at three months. In the control group, some 23% had given up at three months.

It is thus very likely that the extended physical contact caused the oxytocin levels to rise in the skin-to-skin mothers, and thus helped make breastfeeding a pleasurable experience, prompting the mothers to continue.

Curiously, oxytocin also has effects in the baby. Experiments in animals have shown that oxytocin works in two ways as regards nutrient uptake.

First, when the level of oxytocin is high, the pups will be able to go longer without food, without displaying signs of hunger. The theoretical consequences of that for a breastfeeding mother ought to be obvious. If she can assist in increasing her baby’s oxytocin level by providing physical contact (ideally skin-to-skin) her baby will be able to go longer without food, thus reducing the demands on the mother’s time.
Secondly, if a group of pups is taken away from the mother, divided into two groups, where one group is caressed daily by a research assistant (and thus affecting the level of oxytocin) and the other left alone, the caressed group will utilize the supplied nutrients far better than the untouched group. So even though the two groups are given the exact same amounts of nutrients, the caressed group will grow faster. This could explain why some children are growing faster than others – having been exposed to more physical contact, their oxytocin level is higher and they therefore utilize the nutrients of their mother’s milk more efficiently.

In summary, oxytocin seems to affect breastfeeding more broadly than hitherto assumed. The effects of oxytocin on breastfeeding are not simply reduced to the milk let-down reflex, but affect a number of other supporting mechanisms, which in the end will assure that the breastfeeding experience is the pleasant and mutually rewarding experience that every mother is hoping for.

The key to utilizing this insight is to expose yourself as a breastfeeding mother to extensive skin-to-skin contact, carry your baby on your body, look into her or his eyes, take in her or his lovely smell, and soon you will be successfully breastfeeding your baby.

Perhaps you have not chosen this option if you have given birth in the U.S., as so few women have – currently around 0.67%. Consequently, there is only a relatively small chance that you know someone who has personally had the experience of giving birth at home. For some, it may seem unfamiliar that a birth at home should give you a greater level of security and satisfaction with your birth. However, in this article, we will examine a variety of the aspects that differ between a home birth and a hospital-based birth. And although you may in fact never choose to deliver at home, some of the features of a home birth may be an inspiration for the way you choose to give birth in a hospital.

In the small, but relatively progressive country of Denmark in Northern Europe, with a population roughly equal to that of the state of Wisconsin, a group of midwives has been working over the past twenty years in close and mutually beneficial collaboration with obstetricians and hospitals to provide high quality home births. They are simply called “The Home Birth Group.” In the region where their services are available to the general public, the rate of home births has steadily grown to 4.5% of all spontaneous births. This growth has come about by word of mouth and chat room experience sharing, as the vast majority of the participating mothers has been extremely appreciative about their experience and the care they received.

And, interestingly, the midwives involved are also very content with the quality of service they are able to deliver, and express great enthusiasm for their work. As we all know, competence combined with a genuine love for one’s craft is an unbeatable combination, especially when it comes to something as emotionally significant as birth.

In the eyes of “The Home Birth Group” midwives, a birth is not a medical condition that needs to be cured. A birth is likely to be one of the most intense events in a woman’s life and it draws naturally on the inherent strengths and resources of the individual woman. And for that reason, the preparations, the environment and the people surrounding the birth all either empower or weaken the birthing woman in her own endeavors to bring forth a new life. In order for any prospective mother to be able to assess which type of birthing arrangement will suit her best, a relatively systemic or encompassing view of the entire process is required. To reduce security of birth to the availability of medical interventions may just be too narrow a view.

But what better way of describing the salient features of a home birth – and thereby implicitly contrasting the home birth experience with how most hospital-based births are prepared and carried out – than giving the floor to one quite reflected and eloquent mother of two. This Danish mother, Karen Pedersen, has gone through two home deliveries, the most recent one with the help of “The Home Birth Group.” She has also had a long-standing interest in discussing birth experiences with other mothers who gave birth in hospitals.

“Giving birth at home under the home birth scheme (or support team) is a luxury I would want all pregnant women to have as an option for their choice of birth place. With the home birth scheme you get the whole package: knowing your midwives, home consultations, birth tub, maternity care and midwives who make a difference and who clearly love their work.

The entire family was completely confident about the birth – even our oldest 3-year-old daughter. Our birth assistants had also participated in one of the many home consultations, which made them certain of their role. The many home consultations (minimum 7) are a key feature of the program. Consultations which had as their only focus the pregnant woman and her family. Consultations that take the time they take, without constant glimpses at the clock and the impending arrival of the next pregnant woman. Consultations that take the time to cover everything from expectations of the birth to the older sister’s gymnastic games. We knew our midwives, and they knew us. I was not reduced to “another-one-in-the-line-of-this-workday’s-birthing women.” I felt like a whole woman with a family that also needed to be prepared for the birth.

This meant that as the day finally arose, we did not need to talk about a “wish list” for the birth or to tune in on one another. This gave great comfort and encouragement to us – and to the midwives. The maternity days became the ultimate in care, where we talked with our midwives every day, had a visit and even had the heel prick test done at home. This gave a calm environment which ensured a good start on my breastfeeding, and also the chance to talk the birth through and to make the family extension become part of normal family life. I really had a feeling of being taken care of and thought of, of not being trouble to anyone. The telephone was open 24 hours, just as it had been during pregnancy. That is sheer luxury.

The consultations were also a high point for our daughter, who was allowed to attend and listen in. This gave rise to much midwife playing where she felt my stomach and listened with a stethoscope. As the mother does not have to leave the house for several days, which is normally the case for a hospital birth, the siblings do not experience a loss. “Mom is still here for me, and soon with the sister/brother that I too have been longing for.” We are convinced that this has been one of the main reasons we have completely avoided sibling jealousy. We never forget her smile and her happy eyes when she saw her new little sister for the first time. It was love at first sight.

To become a father is a wonderful thing. To see one’s loved one give birth can be an ordeal for some men. Under these circumstances, my husband has experienced the birth as undramatic and homely.

When choosing to deliver at home, you naturally opt out on many things. I am frequently asked about pain relief. For me pain is about security. When I am secure, I can handle more. I have loved my contractions. I was in the space where I felt the most secure, with people I knew, and I knew the pain was good and productive – it made me a mother and it resulted in life.

To give birth is one of the greatest experiences in life. To share it with people I know and trust is the right thing for me. I needed to have the full ownership of my birth. I decided myself what I wanted to eat, when I was going to be examined, and who should surround me. I have been very secure about laying my birth in the hands of my midwives and never doubted that they were making the right choices regarding my birth. If a transfer to a hospital were to become necessary, I knew they would accompany me and still be my midwives, so even the thought of a possible transfer did not disturb me. I trusted their competence. To be a secure birthing woman is a fantastic experience and may even lead to easier births.“

It is this kind of emotionally strong testimonials that have helped gradually increase the rate of home births to the present 4.5% in this region of Denmark. However, one should also bear in mind that such a relatively high rate of home births requires a seamless cooperation between the home birth midwives and the participating hospitals and obstetricians, a well thought out organization and a reasonable work load.

Now, this may all be well for those fortunate Danes who can participate in that program, but what about the bigger picture? How prevalent is home birth in other countries and perhaps most importantly, what are the hard statistics regarding outcomes and medical interventions for home births and for hospital births? And economic costs involved?

In most economically developed countries, less than 1% of all births are carried out at home. One country stands out; Holland, where the home birth rate is still around 30% and where the country has a century-long uninterrupted tradition for home births. This alone ought to vouch for the benefits and safety of home birthing as a concept and system. It is utterly impossible that the Dutch – in their highly advanced society – could overlook significant differences in infant and maternal health and mortality outcomes between home births and hospital births for decades.

A range of prospective and retrospective studies confirm that the outcomes in terms of safety are equal in the two types of settings. The significant difference is that there are fewer medical interventions in the home births (epidurals, artificial induction of labor via e.g. pitocin, episiotomy, etc.). In societies where birth has become politicized due to clashing interests of different professional groups, studies are sometimes proffered that indicate higher risks associated with home birth. However, these findings are contradicted in the responses from investigators in countries where the professional climate is less tense concerning who ought to be in charge of births.

It is, naturally, extremely important to conduct a competent pre-screening for potential birth issues before deciding for a home birth. However, most healthy normal women bearing one child are, in principle, eligible for a home birth. A range of other factors need to be in place as well: experienced midwives who are thoroughly trained in the many time-honored tools and approaches of the trade and who are given the time to acquaint themselves with the individual pregnant woman through several pre-birth consultations; relative closeness to a hospital in case of the need for a transfer; and well-established relations with hospital-based obstetricians who agree with the concept.

One should also bear in mind, that, according to investigations, an average of approximately 12-15% of the home births end up in a controlled transfer to a hospital – so one in seven or eight births is completed at the hospital, but – and this is an important point for many women – accompanied by the midwife who has been following the pregnant woman throughout her pregnancy.

One of the points frequently highlighted by home birthing women is their comfort, feeling they have adequate, even ample time with the midwife, and the resultant complete absence of stress about limited time. This is often contrasted with the same women’s previous experiences with the hospital birth. Normally, more professional time also equals higher costs. However, in the case of home births this seems not to be the case.

Calculations from The Danish “Home Birth Group” indicate that home births are on average 20% less expensive than hospital births. And, if the greater incidence of medical interventions in hospital births is also factored into the cost calculation, home births become even more relatively economic.

It is a question of replacing costs of hospital medical procedures and management (nurses, obstetricians, cleaning personnel, equipment, laundry, etc.) with professional time spent at the pregnant women’s home. In principle, this ought to make the establishment and management of a home birth organization attractive to private medical insurance companies as well.

In “The Home Birth Group” program, time is allocated for a follow-up home visit after the birth, which gives the new mother the chance to recount her birth experience with her midwife and share her own views on the birth. I think that we can all relate to the need to talk about such a fundamental and deeply emotional event with the very people who participated in the process. However, that is rarely done in hospital settings due to time constraints. The follow up visit also ensures that there is emotional and professional support for the vital initiation of breastfeeding and for eliminating any concerns over the newborn’s health status, especially in first time mothers.

And what’s more, “The Home Birth Group” midwives also organize seasonal festive gatherings where “their” mothers (their birthing clients) are invited to attend with their children. In this way, the contact can be maintained, even in the years that follow, under relaxed and structured circumstances. This also gives the midwives the chance to share the joy of “their” children’s growth and development, and the mothers the opportunity to maintain the bond to their midwife.

Every birth marks the beginning of a unique lifelong adventure and relationship. And every woman wants to begin that relationship in the best possible way.

Surely, for a great variety of reasons, home birth is not for everyone in this day and age, but a well-structured approach to home birth does represent some important aspects of how a good and emotionally secure and empowering birth can come to fruition.

Resources:

General overview on home birth
http://www.midwiferytoday.com/articles/homebirthchoice.asp

Scientific investigation into safety aspects of home birth – “Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician”
http://www.cmaj.ca/cgi/reprint/181/6-7/377

The Danish Home Birth Group
http://www.hjemmefoedsler.dk/

My Best Birth’s list of Midwives and Doulas, www.mybestbirth.com
http://www.mybestbirth.com/page/midwives-doulas-1