Ina May's Guide to Breastfeeding
How Birth Practices Affect Breastfeeding
Ihope the preceding chapters have laid to rest any lingering doubts you may have had about your body’s innate ability to produce milk for your baby in the days following birth. Your body works as well as the bodies of your ancestors, almost none of whom had access to any sort of infant-feeding or birth technology. Even though your culture may make you feel uneasy about breastfeeding (depending upon where you live), you are still part of a species that has existed successfully on this planet for at least two thousand generations and has, for the most part, depended upon artificial feeding of its young for little more than half a century. There’s another blessing—your baby’s body has the same level of innate wisdom that yours does and is programmed with similarly awesome survival features.
At the same time, it’s important to recognize that your ability to produce the appropriate hormones at the necessary times during and after birth to facilitate a great start in breastfeeding depends a good deal— perhaps more than you might realize—upon the environment in which you give birth and the birth practices commonly used there. Wherever you choose to give birth, make sure that it is the type of environment that takes account of the needs of you and your baby just after birth, facilitates breastfeeding by giving you and your baby uninterrupted time to relate with each other (if all is well with you and your baby), and provides you with the kind of support that helps you solve any problems that you might meet as you and your baby begin this new phase of your life together.
Choosing where and how you will give birth is one of the most important preparations you can make for a good breastfeeding experience. I have been in hospitals in which the most commonly performed birth practices combined to almost rule out breastfeeding for most women, and I have been in others where nearly one hundred percent of the women who gave birth were breastfeeding their babies when they left the hospital. In this chapter, I’ll present the best evidence I can to help you make educated decisions about birth choices that may affect your success in breastfeeding. These include the possibility of hiring a doula, the positions that you may assume in labor and birth, your ability to move around freely during labor, strategies for dealing with pain during labor, how much skin-to-skin contact you can have with your baby during the first half hour to hour following birth, and the amount of contact you have with your baby during a hospital stay.
I’ll also discuss how common obstacles to breastfeeding—such as early separation from your baby, an epidural, a vacuum extraction, forceps delivery, or a cesarean—can be overcome. None of the above circumstances will make your breastfeeding experience any easier, but lots of women who have had these interventions are able to breastfeed. If you have had one or more birth interventions, though, you may have to be extra persistent to continue nursing and you may need the help of a dedicated lactation consultant—not just while you are at the hospital but sometimes even after you return home. Fortunately, most hospitals have lactation consultants available, and others specialize in the counseling that many women need during the first weeks of breastfeeding. If you do have trouble with nursing after birth interventions, you must not get too frustrated and discouraged—remember that you and your baby are genetically hardwired to make nursing work and that many mothers have overcome similar obstacles.
In my own first breastfeeding experience, my daughter was born by a mandatory forceps extraction shortly after I had been given a dose of Demerol (meperidine) followed by a caudal anesthesia, which temporarily paralyzed and numbed me from the waist down. I hadn’t wanted either form of pain medication, so these interventions came as a rude shock to me. The caudal meant that I was warned not to lift my head even an inch for the next twelve to fourteen hours, lest I get a spinal headache that might stay with me for three months. Another nonnegotiable item was the chance to see my baby before she was twenty-four hours old. Despite these gross interventions (there was an episiotomy too), my daughter latched on to my breast as soon as I cuddled her close enough to make it possible. It was sheer good luck that she was brought to me at a time when she was wide awake and alert and not too full of infant formula to keep her from being interested in nursing. I had the additional good fortune to have a roommate who gave birth shortly before I did, and she was one of the mere twenty percent of women in the mid-1960s who decided to breastfeed. I just imitated her. I have no way of knowing whether I would have been successful without her good example.
Doulas Improve Birth Outcomes, Breastfeeding, and Mothering
Doulas are trained and experienced in giving continuous emotional and physical help throughout labor. In times past, it was common knowledge that it was easier for women to go through labor and give birth if they were provided with the continuous presence and kindly (nonmedical) advice of female friends or relatives. Nowadays, more and more women are turning to doulas for help during labor. Physicians, midwives, and nurses are hard-pressed to give this kind of attention, since they are typically required to look after several different women on any given day and cannot be continuously present in one woman’s labor room. Evidence for the positive impact of the presence of a supportive relative, midwife, nurse, or doula at the side of a laboring woman is quite strong: Many studies have found that women with labor support had shorter labors and much less need for pain medication, intravenous oxytocin augmentation, forceps, vacuum extraction, and cesarean section than women who labored without this care.1–3 Not surprisingly, the greater chance you have of a shorter, less exhausting, undisturbed labor and birth, the greater will be your ability to enjoy the important time after birth when nature intends that you bond with and begin to breastfeed your baby. On average, having a doula with you during labor halves the time of labor as well as the likelihood of having a cesarean.
If you think you can’t afford to hire a doula, please talk to your physician or midwife about whether there is a volunteer doula service in your area. If there isn’t, maybe one of your girlfriends or relatives would like the idea of being your companion during labor and birth. If she is sympathetic and does some reading about what a doula does, she may save you a lot of unnecessary stress during labor.4Whether she has breastfeeding expertise or not (it’s a good idea to find out), her help during labor may prove invaluable.
Any midwife who has assisted out-of-hospital births over a period of years has encountered cases in which labor was hampered by the presence of too many well-meaning observers. This is most likely to occur during the opening phase of labor, which might be meaningfully described as the entry to a trance state. At this time, much depends upon the behavior of everyone present. Though no one who attends your birth will want to make your labor any harder, some family members may be compassionate enough to know how to make their presence helpful, and others may prove to be harmful distractions, slowing your labor unintentionally. Depending upon your comfort level, it may make you anxious to have even two or three companions during birth (for instance, if you grew up in a family in which the bathroom door was always locked and bodily functions were never discussed). In general, it’s better not to allow people to be with you during labor and birth unless you are really certain that their presence is going to be valuable to you. A sensitive doula can be helpful in getting any well-meaning but inhibitory people out of your immediate presence during labor. This will probably be easier for her to do than for you or your partner, since she does not have a personal relationship with your guests. For example, if some of the people in the room where you’ll be laboring are texting or watching television to pass the time, your doula may suggest that they do this in another room, since it is unlikely that their presence is helping you.
It’s far better to have a doula than to write out a birth plan, because labor rarely proceeds according to anyone’s plan.
Freedom to Choose Maternal Position
in Labor Helps Breastfeeding
If you have ever watched different kinds of mammals in labor, whether in real time or in a video or film, you probably noticed how much they move. Among land mammals, there is much swaying of the hips, shifting of weight from foot to foot, and other movement that may seem purposeless to the uninitiated. Marine mammals tend to be active in labor as well. I remember watching a video of a pregnant killer whale who swam in energetic spirals in the water, twisting and turning to help her baby find her way out. There are reasons for these movements—sometimes the baby is not in the best position to exit the womb and needs to shift in relation to its mother’s body. For instance, if a mare’s foal is malpositioned for birth (the foal’s spine is near the mare’s belly instead of near her spine), the mare will lie on the ground and throw her entire body back and forth to help her baby rotate to a more favorable position. The same thing can happen in humans. Midwives know that when a woman stays in the same posture throughout labor and her baby is poorly positioned, the baby is unlikely to spontaneously move into a better position for birth. On the other hand, if the woman moves from lying down on a bed to her hands and knees, changing positions frequently, she can sometimes help the baby roll a full 180 degrees. This might prevent an unnecessary C-section.
Many women don’t realize this, but labor pain is accentuated by having enforced stationary positions throughout labor. According to Listening to Mothers II (a nationwide survey of 1,600 U.S. women, each of whom gave birth to a single child in 2005), two-thirds of U.S. women now get their main information about childbirth from television rather than from childbirth-education classes. This means that most of the births they have seen were to women on epidurals lying still during labor, waiting for it all to be over. Seeing this kind of birth over and over again causes a subconscious imprint on the mind, and many women develop enough fear of the pains of childbirth that they block the messages their bodies give them about other positions they might take in labor. Others may simply fear diverging from the norm.
A woman in the first stage of labor may find it beneficial to try several upright positions: standing, perhaps leaning on a counter or tray table; slow dancing with her partner; sitting while leaning forward or propped up with pillows; squatting; or sitting in a rocking chair. Sometimes one position suffices, but laboring women usually like to change from one position to another as labor progresses. One of the most effective labors I ever witnessed was that of a first-time mother giving birth to a very large baby. She moved through the first part of labor very efficiently by belly-dancing while putting as much of her weight as possible on a long staff she was holding to steady herself. She then pushed her baby out while leaning on the bed in a kneeling position.
A woman’s position during labor and birth may affect her ability to breastfeed in a couple of ways. Dr. Roberto Caldeyro-Barcia, an Uruguayan obstetrician, was one of the first to scientifically investigate the effects of maternal position on labor. In 1979 he published a study now regarded as a classic, which demonstrated that mothers in a “vertical” position had thirty-six percent shorter opening stages of labor than “horizontal” women; the “vertical” women also reported less pain than the “horizontals.” Walking helped labor progress as well, because it brought the pressure of the baby’s head against the cervix, helping it to thin and open. And the “vertical” mothers’ babies’ heads were less apt to be extremely molded just after birth, indicating a somewhat smoother passage through the mother’s birth canal. Equally important, the babies of women who gave birth in upright positions had less fetal distress at birth.5 These factors all increase the chances that a woman will have a good early breastfeeding experience.
Dr. Caldeyro-Barcia’s research also showed that requiring mothers to give birth lying flat on their backs, with their legs in stirrups, can compress the mothers’ major blood vessels, preventing adequate oxygenated blood from flowing to their babies. Women who are mobile during labor are much less likely to face this problem.
The policy at some hospitals is that there should be electronic fetal monitoring throughout labor, which usually means laboring women are confined to bed. You should be aware, though, that good research shows that listening intermittently to the baby’s heart rate with a handheld Doppler is an equally effective way to monitor the baby’s condition. Many hospitals require a twenty-minute period of continuous monitoring, which, if favorable, can be followed by intermittent monitoring with the handheld device.
Eating and Drinking During Labor
The practice of prohibiting mothers from eating and drinking during labor began in the United States during the 1940s, when a considerable proportion of vaginal births happened with the mother under a general anesthesia. This type of anesthesia causes nausea, and the danger it introduced was of women vomiting while unconscious and then inhaling some of the contents of the stomach. This complication could potentially lead to a fatal form of pneumonia.
By the second half of the twentieth century, it had become rare for women to give birth under general anesthesia. The newer forms of anesthesia (epidural and spinal) no longer made women unconscious or nauseous. Given these new conditions, it would have made sense to relax the routine prohibition of eating and drinking during labor, which is, after all, very hard work for most women—work that requires that energy be replenished in some fashion when it lasts more than seven or eight hours. Though some women will indeed be able to give birth within that amount of time, many more will not—especially if they are restricted in their movements because of intravenous lines, electronic fetal-monitoring systems, and/or epidural anesthesia. My midwifery partners’ and my experience with about 2,500 women over three and a half decades has shown us that many women can safely labor for twenty-four hours, or even more, as long as they are given some real sustenance if they desire it.
I recommend that you look for a maternity service that is flexible on the issue of eating and drinking during labor. If you can’t find one, it’s a good idea to eat a high-carbohydrate meal before leaving for the hospital. Conserving your energy is important, not just in terms of labor but also for breastfeeding. Eating and drinking as needed will help you be more alert for your first interaction with your baby.
The Effect of Pain Medication on Breastfeeding
If you are planning for your first baby and will be giving birth in a hospital, you may have already considered taking some form of pain-relieving medication during labor. Before you choose, it makes sense to consider the advantages and disadvantages of the medications you are likely to be offered if you are planning a vaginal birth. Knowing something about alternative methods of dealing with labor pain is also worth your consideration. There is no question that we all have to be grateful that we have medications to make procedures such as surgery painless. At the same time, the use of painkilling medications has always involved certain risks to mothers and babies that must be weighed for their use in labor, especially in the early part.
The epidural is the best-known form of pain relief for labor in the United States. Even so, there can be some unwanted side effects associated with the epidural that may have some impact on getting a good start with breastfeeding.6–8 Women who have epidurals must also be given intravenous fluids to counteract one of these side effects—drastically lowered maternal blood pressure, which, if left untreated, could cause a sudden drop in the baby’s heart rate. The extra fluid from the IV may make your breasts more swollen than usual in the days following birth, which can make it difficult for your baby to latch on correctly.
Fever during labor is about five times more likely when an epidural is used than when the mother is unmedicated. The cause of this fever is not well understood, but it can mean a higher likelihood of your baby being stressed at birth, having poor muscle tone, needing resuscitation, and having seizures during the first few days, according to one large study.9Another drawback is that the epidural fever cannot be distinguished from a dangerous intrauterine infection unless the baby is evaluated. Such evaluation involves prolonged separation from the mother, possible admission to special care, painful tests, and usually antibiotic treatment until the test results are available. More than three times as many epidural babies were subjected to such evaluation as nonepidural babies, according to the above study. All of these interventions can interfere with the initiation of breastfeeding.
At the same time, a Toronto-based study published in 1999 found that in a hospital that strongly promotes breastfeeding, using epidurals for labor-pain relief does not interfere with breastfeeding success (the new mothers and babies were observed at six weeks following birth). An impressive seventy-two percent of the women who had epidurals were fully breastfeeding. However, thirty-six percent of the women in the study did have difficulty starting breastfeeding in the hospital because of sore nipples or difficulty latching.10 It is highly probable that the results of this study may not be quite so easy to achieve outside of Toronto, which is home to one of the best breastfeeding clinic systems in the world, run under the guidance of Dr. Jack Newman, a well-known pediatrician-breastfeeding consultant and author. The good news that we can take from this report is that with excellent breastfeeding support over the first six weeks, a high proportion of women who have had epidurals can successfully breastfeed.
If you think there is a good chance that you might want an epidural, try to plan your care to take place in a hospital with nurses and lactation consultants who have a strong commitment to helping breastfeeding mothers get off to a good start.
Tranquilizers such as Valium, sedatives, and sleeping pills are all sometimes used to reduce anxiety and tension in laboring women, but they do cross the placenta and interfere with the baby’s ability to breathe, to suckle, and to maintain a healthy muscle tension (tranquilized newborns tend to be limp). Such medications do not take away pain but rather increase pain tolerance. Nonetheless, they are still widely offered in U.S. hospitals.
Narcotics work on the central nervous system and would be effective at significantly reducing labor pain if they could be given in sufficient amounts. This is not possible, however, because doses high enough to lower labor pain are not considered safe for mother and baby. Demerol (meperidine) is still used as an analgesic in some U.S. maternity wards. A relatively small dose, given intravenously or by injection, can cause sleepiness, and it often causes nausea, vomiting, and a drop in blood pressure. Once administered, it crosses the placenta and reaches the baby in only two minutes. Don’t expect a significant drop in pain.
Some studies have shown that babies exposed to Demerol and other narcotics have long-lasting effects when it comes to nursing.11–12 Even if your baby is awake and appears to be alert, she may still have problems breastfeeding. A Swedish study of women given Demerol in labor found that twenty minutes after birth, more than half of the babies in the study were still too sedated to suckle at all. Eighteen percent had a disorganized suck. The authors found that the half-life of Demerol in a newborn ranges from thirteen to twenty-three hours.13
Stadol (generic name: butorphanol) and Nubain (nalbuphine) are other narcotics that are often used for labor analgesia. One study found that babies medicated with these narcotics were forty-four hours slower to establish breastfeeding than those who had no narcotics.14
Learn About Techniques for Reducing Pain
Before we leave the subject of labor pain, let’s look at some of the often-overlooked nonmedical remedies that have proven effective for many women. As I’ve discussed, unrestricted movement during labor is a key way to decrease pain naturally. If you experience a lot of back pain, you may also try getting on your hands and knees. Another option is hydrotherapy, in the form of a shower or a warm, deep bath (if this is offered by the hospital you plan to use). Lots of women who get into water in early labor don’t want to get out, because they find it so relaxing.
A physical-therapy birth ball is an excellent and inexpensive labor aid. You can use it to support your weight while kneeling, sitting, or standing during labor. Many mothers also find this ball useful after birth, as it provides you a great way to sit and hold your fussy baby while gently bouncing. The 65-cm-size ball is the one that is most widely used by women of average height. Choose a size larger or smaller, according to your own needs.
The detail of a famous sculpture by Bernini, “The Ecstasy of St. Teresa,” shows the facial expression that I often see in the later stages of labor. Mind you, St. Teresa was not depicted giving birth; in fact, she was being visited by an angel, whose spiritual presence was so powerful that it put her into an ecstatic state. It’s a good one to meditate on while you are still pregnant, as it’s one of the expressions I most like to see on a woman in labor: The open jaw indicates surrender to the natural forces of labor. This goes with an optimal mix of birth hormones, which is the best preparation for an optimal mix of lactation hormones.
As part of your preparation for labor, I would recommend that you view the film Orgasmic Birth, as it offers you a chance to watch several women having un-medicated, ecstatic births.
Detail of Bernini’s “The Ecstasy of St. Teresa”
The Sensitive Period Just After Birth
Farmers and those who raise animals have always known that there is a sensitive period just after birth. I first became aware of this concept at the age of nine, during the summer I spent at my aunt’s farm. Besides raising milk cows and many other animals, my aunt Myra raised dogs, and at this particular time she had a bulldog with high needs. The bulldog gave birth to a litter of twelve pups in Aunt Myra’s kitchen. I had never seen such young puppies before and immediately reached out to pick up one of the squirming litter. “Don’t touch that pup!” shouted my usually soft-spoken aunt. I quickly withdrew my hand, stung by her strong reprimand. Aunt Myra then quietly explained that if I had contaminated the puppy with my smell, the mother might reject the puppy or even her whole litter. That incident made a deep impression on me; it provided my first understanding that maternal behavior, which I’d assumed was automatic in animals, could so easily be disrupted by well-meaning but ignorant human interference.
Michel Odent has pointed out that scientific research in the area of imprinting and attachment behavior began in the 1930s with Konrad Lorenz’s legendary experiment with ducks. Lorenz reported that one day he had placed himself between newly hatched ducklings and their mother and then imitated the mother’s quacking sounds. The ducklings imprinted upon him and attached to him for the rest of their lives, following him as he walked around the garden.
Studies of the sensitive period in mammals have looked at various species, including rats, sheep, and goats. General findings have been that later separation of mother and young could be tolerated—that is, long-lasting bonds had been formed—as long as the separation did not occur during the sensitive period just after birth. However, in sheep, if the separation occurred just after birth and extended for four hours or so, half of the ewes simply wouldn’t take care of their babies when they were reunited. In another study, when ewes were given epidurals in labor, they refused to take care of their lambs at all.
We humans seem to be much more adaptable than other mammals are when it comes to forming bonds with our newborn babies, even if we haven’t had uninterrupted, skin-to-skin contact during the first hour following birth. All the same, many studies have made it clear how important this period can be to mothers who want to breastfeed their babies.
Delayed Cutting of the Umbilical Cord
You may be surprised to know how much the timing of umbilical-cord clamping can affect your breastfeeding experience. Despite the lack of any solid evidence that haste to cut the cord benefits baby or mother, immediate clamping of the umbilical cord is standard procedure in most U.S. hospitals, as if more placental blood would be detrimental to the newborn baby. This practice is probably a habit formed during a time when most babies were born to women under general anesthesia; many of these babies required immediate resuscitation, so their cords were clamped right away. Within the midwifery model of care, on the other hand, the tendency is to delay clamping and cutting the umbilical cord. The assumption is that a newborn will benefit from receiving the additional volume of blood that will be squeezed into her body in the first few minutes of life—as much as thirty percent of her total blood volume.
Certainly, nature has provided various designs among different species of mammals regarding when and how the placenta ceases to be a part of the fetus’s or newborn’s life-support system. Elephants and several other species of mammals, for example, have an umbilical cord that isn’t long enough to enable the infant to be delivered until the cord breaks. There is usually a weak place in the cord, which snaps during the birth process, unless the placenta releases at the same time the infant is expelled. We can guess from this biological design that elephant calves probably don’t need any more blood than the placenta transfers to them before the infant begins to move down the birth canal. But can we make the same assumption when it comes to human infants?
Judy Mercer, a U.S. nurse-midwife and professor of nursing, has been researching this subject for more than three decades. In 2006, her landmark study of early vs. late cord-clamping gained international attention by showing that a brief delay in clamping the cords of babies born before thirty-two weeks prevents—to a significant degree—bleeding in the brain and infections.15 The National Institutes of Health found her data so promising that she was recently awarded $2 million to carry out a larger study that will look at the results of delayed clamping for full-term babies as well as after cesareans.
It is really odd that midwives and nurses who favor delayed clamping are in the position of having to prove that a few seconds’ or minutes’ delay has advantages to the baby. Midwives in out-of-hospital birth settings almost unanimously favor delayed cord-clamping—that is, waiting to clamp at least until pulsation of the cord has stopped. We usually keep the baby on approximately the same level as the mother, since we place her directly on her mother’s abdomen just after birth as we wait for the placenta to be delivered.
One more important reason to negotiate with your physician or midwife for delayed cord-cutting is that, if your baby is still attached to your body in this way, any separation of the two of you will also be delayed. Your baby will have a much easier time adjusting to breathing and will be less likely to suffer from anemia if her cord is allowed to pulsate for several minutes after birth. (A vaginally born first twin may sometimes be an exception.)
A new trend called “cord blood banking” has been heavily marketed recently. What you may not realize is that such cord blood extraction requires immediate clamping of the cord and a rigorous process that can prove disruptive during the magical time just following birth.
Your Baby’s Initial Evaluation
Step one for getting the best possible start at breastfeeding is for you and your baby to be as close together as possible just after birth. Skin-to-skin contact is especially important during the first hour, because of the hormonal changes taking place in you and your baby. These are magic moments for both of you. Biologically speaking, you two are still a unit and should be treated as such. Your baby’s touch, movements, and “begging” sounds cause you to release the hormones that protect you against excessive blood loss, and your body’s warmth protects your baby from loss of body heat. This is also a time for you to begin to learn your baby’s cues—what her various sounds and movements mean.
Swedish researchers studied the benefits of skin-to-skin contact in the first hours after normal birth. They hypothesized that babies would cry less in their first hours of life if they had skin-to-skin contact with their mothers. The babies who were randomized to the skin-to-skin-contact group were compared with a group of babies who were similar in every other way except for being swaddled in double blankets and placed in a bed next to the mother. Not only did the skin-to-skin group cry less, they also had higher body temperatures and were less apt to experience low blood-sugar levels ninety minutes after birth than the swaddled group.16 (A baby with a higher temperature is more likely to have the energy to latch on to the breast than one whose temperature is lower.) Nature didn’t intend for mothers and their babies to be separated from each other after birth. In fact, immediate separation between mother and baby is one of the most efficient ways to make the initiation of breastfeeding more difficult.
Once your baby is born, your birth attendant will want to observe her condition. The initial evaluation can easily be done with her facedown on your abdomen or chest, since all that is necessary is the observation of her breathing, heart rate, muscle tone, reflex irritability, and skin color. The score given from this observation is called an Apgar score, named after Dr. Virginia Apgar, who invented the system several decades ago (as a way to assess babies exposed to medications).
Usually, within the first hour, your baby will be given a more thorough examination that checks for heart and lung function and looks for any problems that she might have, whether internal or external. It has long been the habit of most U.S. hospitals to do both this examination and the Apgar scoring on a special infant examination table under an infant warmer. However, both can be done just as well on your chest, and without immediate cutting of the umbilical cord. If done this way, the examination needn’t upset your baby, and it will also give you a chance to talk with the examiner about what she is doing.
One of the most important recent studies on skin-to-skin contact, which, like the study mentioned on the previous page, was carried out in Sweden, describes the inborn behaviors that take place when mothers and newborns have uninterrupted contact. The researchers found that even painless procedures such as weighing, measuring, and bathing the newborn interfere with inborn feeding behavior.17 Your baby’s weight and height will not change during the first hours of life, so there should be no harm in delaying these procedures.
As for bathing (usually a routine hospital procedure just after birth), babies aren’t born filthy. Blood, if present, may be gently wiped away, but the rest of what’s on the baby’s skin is conducive to the early initiation of breastfeeding, because the smell of amniotic fluid is an important stimulant to the nervous systems of both mother and newborn. The same principle should be applied to any attempt on the part of the nursing staff to wash your breasts. Two studies, prompted by scientists’ awareness of the tendency for newborn mammals to find the smell of amniotic fluid attractive, considered the issue of smell in human infants. In one study, the mothers and babies were kept together, and the mothers washed one of their breasts. More than seventy percent of the babies moved toward the unwashed breast.18Another study separated babies from their mothers and placed them in a cot with a breast pad carrying their mothers’ odor a few inches from their nose. The same babies were also given a clean breast pad. Not surprisingly, most of the babies moved toward the pad that smelled like their mother.19
Of course, circumstances sometimes require separation, as when a baby needs to be transferred to intensive care or a mother has more than normal blood loss. The point is that the mother and baby’s need for each other should be recognized and fulfilled as much as possible throughout the hospital stay. Even if your baby has difficulties after birth and needs intensive care, it is usually possible for you to have a few minutes with her before she is transferred. If your baby is placed in intensive care in the hospital where you gave birth, you and other family members will be able to visit her there. Most intensive-care units have staff members whose job is to keep you informed about how your baby is doing and to reunite you with each other at the earliest opportunity.
If your baby is born prematurely or small for gestational age, you should know about the benefits of what is called the kangaroo-mother care model. First developed and described in Bogotá, Colombia, this low-tech method of care stabilizes premature babies through early and prolonged skin-to-skin contact in a kangaroo position between the mother’s breasts. The method was initially promoted because of its cost-effectiveness, but subsequent research has shown that it is equally effective in countries with plenty of resources.20 Besides all of the benefits that I have already discussed regarding early skin-to-skin contact, kangaroo-care premature babies are twice as likely to breastfeed, compared with incubator babies (eighty-two percent versus forty-five percent in one study). Mothers of kangaroo-care babies produced more milk, and their babies cried less and maintained their body temperatures better.
A California nurse, Carol Melcher, developed an ingenious “intervention” in the care of newborns that has significantly improved the initiation of breastfeeding in those hospitals that adopt it. Her method calls for new mothers to be encouraged to hold their newborns skin-to-skin during the first two hours following birth and as much as possible thereafter, unless there are specific medical problems with either that would rule this out. Nurses in hospitals that adopt her method postpone such interventions as the newborn bath, glucose sticks, footprinting, and eye treatments until after the first two hours, thus taking advantage of the strong suck reflex that a baby ordinarily has during the first hour or so following birth. If you plan to give birth in a hospital, you may want to find out if the nursing staff there is familiar with Melcher’s “Breastfeeding Hospital Policy Recommendation #5.” See Resources for information on how to access this policy recommendation. It is based upon very solid evidence.
Circumcision of newborn boys is a widespread practice in the United States that is usually performed before hospital discharge. With early discharge having become the norm, many babies are circumcised just a few hours after birth. Circumcision’s impact on breastfeeding stems chiefly from its effect on the baby—though a local anesthetic may be used to partly numb the pain, this procedure can be both painful and extremely frightening for your baby. Newborns who undergo painful surgical procedures have high levels of stress hormones, which speed up their heart rates and suppress the high oxytocin levels that normally trigger their innate impulses to seek the breast.
There are no medical reasons compelling routine circumcision. The American Academy of Pediatrics recognized this in its 1999 statement: “Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision.” The Canadian Paediatric Society made a similar statement in 2002, without adding the phrase about potential medical benefits, while the British Medical Association’s 2003 statement was the most strongly worded of all: “The BMA does not believe that parental preference alone constitutes sufficient grounds for performing a surgical procedure on a child unable to express his own view…. Parental preference must be weighed in terms of the child’s interests…. The BMA considers that the evidence concerning health benefit from non-therapeutic circumcision is insufficient for this alone to be a justification for doing it.”
Because newborn circumcision was routine for so many decades in the United States, many parents-to-be lack information about what happens if there is no circumcision. Almost all newborn boys have tight foreskins during their first year of life. By the age of two, about half of boys’ foreskins will have loosened from the head of the penis so that the foreskin can be retracted completely. (It’s important that the foreskin not be forcibly retracted.) Once this is possible, it’s an important part of hygiene that the foreskin be pulled back during a bath so that the accumulation of smegma can be removed. Only rarely does a circumcision become necessary because a foreskin cannot be retracted later in childhood or adulthood.
If you intend to breastfeed and you decide to go ahead with circumcision of your newborn boy, I recommend that you schedule it after your baby has experienced pleasure at your breast. Every lactation consultant I know has learned from experience that babies who undergo circumcision before they get a chance to suckle have more trouble taking the breast than those who are not frightened or subjected to a painful treatment during the first hours of life.
The same goes for immunizations. In some hospitals, it is routine to give all newborns immunizations very soon after birth, regardless of whether the babies have yet had a chance to nurse. Injections almost always hurt, and the experience of getting one soon after birth can cause a sensitive baby to become too tense and distrustful to feed at the breast for a while. When a twenty-four-or forty-eight-hour hospital stay is the norm, many babies have so many painful procedures within the first day of life that a chance at the breast is made unnecessarily difficult. The question then becomes: What justification is there for giving a newborn an immunization during the first day of life?
I can see only one situation when it would make sense to have an immunization on the first day of life: When a mother tests positive for hepatitis B, the vaccine should be given to the baby within twelve hours of birth. If possible, then, delay the shot until the half-day mark. The next immunizations can wait until your baby is two months old, so why not wait? These include the oral polio vaccine; the diphtheria, pertussis, and tetanus vaccine; and the hemophilus influenza B vaccine.
Rooming-in means that you and your baby share the same room during your hospital stay instead of her being brought to you only at scheduled times. About sixty years ago, it became routine in U.S. hospitals for newborn babies to be taken away from their mothers and kept in a central nursery, where doctors and nurses could look after them. Dr. Marsden Wagner has called this practice the “biggest pediatric mistake of the last 100 years,” referring to the frequent infectious epidemics in central nurseries, which caused significant loss of newborn lives.21 Other problems with this setup are that it interferes with successful breastfeeding, deprives mothers of the chance to bond with their babies, creates multiple chances for mix-up of babies, and interferes with the development of mothers’ self-confidence in caring for their newborns. It has to be said that these nurseries also led to a remarkable degree of ignorance about breastfeeding and its value for mothers and babies alike.
Starting life in a central nursery means little or no skin-to-skin contact between mother and baby, which results in less prolactin and therefore less milk than nature intended. It also creates opportunities, as well as temptations, for nurses to give your baby a pacifier or a feeding of infant formula, if they don’t happen to be strong advocates for breastfeeding. Rooming-in, on the other hand, allows you to have as much skin-to-skin contact as possible with your baby. It means that you can breastfeed your baby as often as she would like—the way nature intended. Women in hunter-gatherer societies carry their babies next to their bodies and feed them many times a day once their milk supply is established.
The hospital practice of separating mothers and babies was not created to stop breastfeeding and bonding. That often may have been the result, but the practice began for other reasons. During the 1950s and 1960s, there were few medical studies that could be cited as evidence for keeping women and babies together, which made it difficult for anyone to argue in favor of it. At the same time, doctors and nurses received little or no education about the value of breastfeeding, and no one discussed the development of mothers’ feelings for their babies and how this might be affected by hospital practices. This was also the era of general anesthesia and scopolamine, when a large proportion of U.S. women were so medicated in labor that they woke up unaware that their babies had been born. Many others—like me, for my first birth—were given a form of spinal anesthesia that made it necessary to avoid lifting their heads for half a day after giving birth if they didn’t want to suffer a prolonged and severe spinal headache. Under these conditions, the central nursery became a necessity, because so many new mothers were unable to care for their babies during the first hours following birth. In many hospitals, a mother might see her baby only once during the first twenty-four hours and twice during the second day. No wonder so many people in this country began to think that breastfeeding didn’t work!
During those decades, most North American women accepted the routine separation from their babies as medically necessary. I certainly did. No one suggested that I might want more access to my baby than the hospital was prepared to offer, and I never thought to ask what the rules about this were. I later found out that some nurseries three to four decades ago were so controlling that they forbade new mothers from unwrapping the blankets to have a closer look at their babies. Is it hard for you to believe that new mothers could be so easily intimidated as to obey such a crazy rule? Literally millions of women did, myself included.
I still remember how unprepared I felt when it was time to be discharged from the hospital, when my baby was five days old. During those few days, I had never once been trusted to change her diaper, dress her, or walk with her in my arms. The hospital policy of separation managed to convince me that the “experts” were better at caring for my daughter than I could ever be. That’s a far cry from the kind of self-confidence I like to see in the new mothers in my care.
All this began to change during the 1960s and 1970s, when there was a resurgence of interest among women in being awake and aware during birth and in breastfeeding. At the same time, researchers in different parts of the world who were skeptical about the wisdom of routinely separating mothers and babies after birth began to carry out studies that looked at the unanticipated effects of early separation. One of the most intriguing of these early studies compared a test group of babies who were allowed skin-to-skin contact just after birth to a group of babies who didn’t have such contact. The researchers noticed that in the skin-to-skin group, if the newborn babies were given enough uninterrupted time with their mothers and were left quietly on the mother’s abdomen, gradually they crawled up to the mother’s breast, found the nipple, and began to suckle. Fifteen out of sixteen babies were able to attach themselves in this way without any help—provided that the mother’s labor was unmedicated and the babies had not been immediately taken away from their mothers for baths, vitamin K, weighing, or eye ointment. This was a revolutionary finding for wealthy countries, where it had become an article of faith among the medical profession that newborn humans did not have the skills exhibited by every other type of newborn mammal on the planet. A teaching video was later produced where these babies demonstrated to the world that they came out of the womb as well prepared as a puppy, a baby mouse, or a piglet (you can insert the name of any other mammal) to find the all-important nipple and to get down to the business of bringing in the milk supply that would sustain them during infancy.22
To summarize, here is a list of the tangible benefits of rooming-in that have been documented in scientific literature:
· Your milk production is likely to begin earlier.
· Your breasts are less likely to become engorged.
· Your baby is likely to have a faster weight gain.
· Your baby will be less likely to get jaundiced, because of quicker availability of your colostrum and milk. Practically speaking, this means less likelihood of your baby being separated from you for treatment of jaundice under bilirubin lights.
· Your baby is less likely to get an infection.
· Your baby will be more content and will cry less. Remember, she actually knows the difference between you and the nurses and prefers being held by you.
· You’ll learn your baby’s facial expressions and signals earlier.
· Your self-confidence as a mother will be enhanced.
· Caring for your baby from the very beginning will help you develop a stronger attachment to her. (Not everyone feels this strong bond right away, but solid evidence shows that close early contact helps it to develop.)
· You’ll get more and better rest with rooming-in, because skin-to-skin contact with your baby will stimulate higher levels of the stress-reducing hormones oxytocin and prolactin in your system, and these hormones help you sleep better.
· You are less likely to experience postpartum depression.
Some hospitals offer so-called “modified rooming-in.” This means that your baby spends most of the day with you in your room but is taken to the nursery each night. While modified rooming-in may sound good, and it is certainly preferable to a complete separation from your baby, it can present problems in getting started with breastfeeding. Babies tend to sleep a lot during the first two days of life, and some do not develop the kind of strong cry that might prompt the night nurses to bring her to you for a feeding. Some nurses might even consider it a kindness to you to give her a bottle during the night, letting you sleep. However well intentioned, this practice can delay your milk from coming in and work against a smooth start to breastfeeding. Additionally, the milk you give after midnight has a higher fat content, which your baby will miss out on if you are not able to give her a nighttime feeding. In view of this, I recommend that you take a tour of the hospital where you plan to give birth, to get a look at the facilities and see for yourself how that hospital defines rooming-in and how well this option is promoted. A relatively empty central nursery is a good sign that the staff regards rooming-in as the norm rather than an eccentric choice. A completely empty one is even better.
An empty central nursery in an Austrian hospital
Remember that it’s important to know how full the nursery is during the night as well as during the day. Also, take note of the attitude of the person giving you the tour. Is the staff member enthusiastic about twenty-four-hour rooming-in? If modified rooming-in seems as far as the hospital is willing to go to accommodate breastfeeding, you may want to explore other options to see if you can find a more breastfeeding-friendly environment.
Despite the recommendations of the American Academy of Pediatrics, the choice of rooming-in is not available at all U.S. hospitals. The Listening to Mothers II survey (conducted by the Maternity Center Association) of 1,600 U.S. women who had given birth within the last two years found that only about sixty percent of the mothers interviewed had rooming-in.
Here are some questions that you can ask of your hospital to find out how much support the maternity care staff will give you and whether there will be any resistance to you having uninterrupted skin-to-skin contact with your baby during the first two hours and rooming-in for the rest of your hospital stay.
· Can you do the initial examination of my baby with her beside me?
· Can my baby be in the same room with me throughout my hospital stay?
· Is there any medical reason why my baby can’t be with me?
· If there is any reason why my baby has to be taken from me, what care will be given to her?
· Who will be giving that care?
· When will my baby be brought back to me?
· Are you aware that I intend to breastfeed?
· Can my baby be given my breast milk during any separation from me?
· What kind of help will be available for me in learning how to breastfeed?
· Is kangaroo care possible if my baby is born prematurely?
Hospitals vary a lot as to whether rooming-in is a possibility for women whose babies are born prematurely.
In hospital units that strongly promote breastfeeding, premature babies are given skin-to-skin contact with their mothers as soon as they are able to breathe without a ventilator. I visited a neonatal unit in Prague, Czech Republic, in which rooming-in was the norm for premature babies as soon as they were breathing on their own. Their mothers were invited to begin to care for them as soon as they were off the ventilator. The pediatricians at this hospital were so convinced of the value of mother’s milk for these tiny infants that they created a living unit large enough for about eight mothers. Each woman had a private sleeping space near a common kitchen and dining room. This arrangement, plus a generous paid maternity leave, allowed these babies to gain weight and strength at an optimal rate.
A neonatal unit in a children’s hospital in northern Estonia was established in the late 1970s to provide medical and nursing care to newborn and premature babies and their mothers. The principles at this unit were twenty-four-hour care by the mother, minimal use of technology, and little contact between the baby and the medical and nursing staff. Each mother was given support by a team of doctors, nurses, psychologists, and massage therapists. She was taught to massage her baby every day and to keep notes on the baby’s state of health. Every room was shared by two mothers, and there was a shared lounge area. The mothers were served meals in their rooms, so that they didn’t have to leave their babies in order to eat. Fathers and other family members were encouraged to visit throughout the week. The medical director of the unit credited this approach with “considerable decreases in the number of infectious diseases,” which meant less need for intravenous antibiotic therapy for the babies.23
The unit was able to compare the weight gain of babies who were cared for by their mothers with that of babies who were cared for by nurses (because these babies’ mothers had decided to leave the job to them). The premature babies in the mother-care group showed significantly higher weight gains than the premature babies in the nurse-care group.
There is a trend toward twenty-four-hour rooming-in in most of Europe. I have been in several European hospitals in which the newborn nurseries were entirely empty at the time of my visit. By 2005, hospitals all across Sweden had phased out central nurseries by converting them into sitting rooms, dining rooms, or combination sitting-dining rooms for parents. Sweden has decided that the hospital has an important part to play in encouraging close relationships between parents and babies, as well as breastfeeding. They have dealt proactively with the possibility that misplaced sensitivity to negative staff attitudes rather than concern for their babies’ needs might prevent some new mothers from rooming-in. Staff retraining did much to remove obstacles in the way of twenty-four-hour rooming-in.24 One study provided what maternity policy-makers considered solid evidence that many new mothers will refrain from choosing rooming-in if they believe that the staff would prefer them to choose nursery care.
Here in the United States, there are varying attitudes about rooming-in among hospital staff members, probably because most hospital staffs have not been properly educated about how this arrangement can benefit both mother and baby. Some nurses who are unfamiliar with rooming-in may even leave obstetrics if rooming-in is phased in at their hospital. On a recent nursing forum on the Internet, one nurse said she was quitting because she couldn’t believe the evidence of the value of rooming-in. She described it as “unsafe policies that put babies in danger.” Another added, “… no dead babies yet. I can see so many things going wrong… aspiration, abducted babies, etc.”25 On the other side, there were some who saw for themselves how beneficial rooming-in can be: “We were very surprised to see that most [mothers] did not protest the change, as it gives them more time to learn how to care for their babies and ask questions while the baby is right there,” said one nurse. Another, who did home follow-up care, said, “I think it is good to remember why keeping mothers and babies together is so important. I would see parents who hardly knew anything about their baby, and mothers with almost no milk production at post-delivery day four or five. I could tell who had spent a lot of time with their baby and who had not….”
Baby-Friendly Hospitals and the
Ten Steps to Successful Breastfeeding
In 1991 the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO) launched an international effort by developing a set of protocols for hospitals called the Ten Steps to Successful Breastfeeding.
The initiative was meant to begin a global effort to improve the effect of hospital maternity services on mothers’ ability to initiate breastfeeding for their babies’ best start in life. The ten steps are applicable to any birth setting, but they were formulated because of the strong evidence that many technology-driven hospital routines and procedures are a large factor in low rates of breastfeeding when mothers and babies are discharged from the hospital.
Step 1. Have a written breastfeeding policy that is routinely communicated to all health-care staff.
Step 2. Train all health-care staff in skills necessary to implement this policy.
Step 3. Inform all pregnant women about the benefits and management of breastfeeding.
Step 4. Help mothers initiate breastfeeding within half an hour of birth.
Step 5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.
Step 6. Give newborn infants no food or drink other than breast milk, unless medically indicated. [Giving supplemental feedings in the first few days after birth is associated with an almost fourfold increase in the risk of being weaned by three months postpartum.]
Step 7. Practice rooming-in—that is, allow mothers and infants to remain together—twenty-four hours a day.*
Step 8. Encourage breastfeeding on demand.
Step 9. Give no artificial teats or pacifiers to breastfeeding infants.
Step 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.
Since 1991, the two organizations have promoted these steps around the world by designating hospitals that fulfill the ten steps as “Baby-Friendly.”26 Hospitals and birth centers that apply for Baby-Friendly recognition are evaluated according to their implementation of the Ten Steps to Successful Breastfeeding and their adherence to the WHO code.
To date, UNICEF has awarded this designation to about 20,000 hospitals in more than 150 countries. In many countries, mother’s milk is considered such a vital national resource that the government requires every hospital to follow the ten steps.
Norway, for instance, had rates of breastfeeding initiation as low as those in the United States in the early 1970s, when only about a fifth of new mothers were breastfeeding their babies when they left the hospital. That country has completely changed its national policies by making sure that every Norwegian hospital in which babies are born is Baby-Friendly. At present, Norway leads the world in breastfeeding, with ninety-nine percent of Norwegian women breastfeeding at hospital discharge and more than eighty percent still breastfeeding when their babies are six months old.27 In the United States in 2006, just seventy-seven percent of mothers were willing to try breastfeeding (but not exclusively) at discharge and only thirty-two percent were still nursing at six months.28 According to a prominent Norwegian obstetrician-gynecologist and breastfeeding advocate, Dr. Gro Nylander, “At present it is more or less accepted in my country that it should be as unusual to feed animal milk to a newborn baby as it is to give human milk to newborn animals….” And yet by far most Norwegian babies are born in hospitals. Clearly it is possible to design hospitals that combine the best of technology with enough restraint in its use to permit nearly every woman who wants to breastfeed to do so.
Baby-Friendly hospitals are not as easy to find in the United States as they should be. As of April 2009, only sixty-three U.S. hospitals in twenty-three states have been awarded Baby-Friendly status.29California, with eighteen such hospitals, has the greatest number, but most states don’t have even one Baby-Friendly hospital.
So far, the lesson has been that Baby-Friendly status happens most often in countries in which the government provides effective direction, information, and resources to expedite the transition from hospital practices that are likely to interfere with the initiation and maintenance of breastfeeding to Baby-Friendly status as the norm. In these countries, breastfeeding rates rise significantly almost immediately.
Obstacles to the Baby-Friendly Hospital
Initiative in the United States
What have been the obstacles to the global Baby-Friendly Hospital Initiative in the United States? According to Diony Young, longtime editor of the journal Birth, the Department of Health and Human Services and the Department of Agriculture played a part in slowing down the movement in the United States, quite possibly because of pressure from infant-formula corporations, who knew that their profits would be reduced if there was a significant rise in breastfeeding rates here. Instead of protecting breastfeeding, the government decided to protect the infant-formula companies. The American Hospital Association (AHA) has also proved to be an obstacle; in the 1990s it opposed the global initiative as an “unwelcome intrusion and potential expense for hospitals.”30 The pressure from the AHA resulted in proposals to change the definitions and requirements for attaining Baby-Friendly status.
U.S. hospitals face certain obstacles that hospitals in other countries may not in attaining Baby-Friendly certification. Twenty-four-hour rooming-in leaves little reason to maintain large, empty central nurseries. At the same time, there are laws in almost half of the states mandating that every hospital that provides maternity services must maintain a central nursery. This means that the room cannot be converted to a sitting or dining room. One large problem for nurses or pediatricians who would like to see their hospitals become Baby-Friendly is that they have to gain the cooperation of the hospital administrators, obstetricians, midwives, family physicians, postpartum nurses, neonatal intensive-care staff, prenatal services, nutritional services, supplemental food programs, and neighborhood health centers to make it happen. Gaining this cooperation can be hard to achieve when there is still the perception that women don’t care whether they breastfeed or not or that the hospital can’t do without the free infant formula, luncheons, notepads, pens, pacifiers, newsletters, crib cards, measuring tapes, in-service funds, conference sponsorships, and patient-education materials provided by infant-formula manufacturers.
Baby-Friendly hospitals must also make sure that pregnant and postpartum women are not exposed while in the hospital or its associated clinics to advertising, booklets, calendars, videotapes, or other materials that can undermine breastfeeding and make artificial feeding appear to be the norm. And hospital administrators and staff must make sure that mothers in their care do not leave the hospital with sample products that have been supplied by infant-formula companies to promote their wares. These include discharge gift packs of formula, feeding bottles, nipples, and pacifiers.
Though the U.S. government does enunciate public-health goals (one of which is to achieve a seventy-five percent rate of exclusive breastfeeding by 2010), it can be argued that, compared with the many other countries in the world with higher breastfeeding rates, it does little beyond that to make breastfeeding more attractive, easier, and more possible for our mothers. I would like to see our government put forth a greater effort to increase the number of Baby-Friendly hospitals in this country.
* Step 7 calls for twenty-four-hour rooming-in for all mothers, but in the U.S. this is interpreted as meaning all those who desire it—quite a step back from the usual definition of “all mothers.”