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I
have to laugh at myself, giving this talk on attachment. Attachment parenting
expert I most certainly am not. And if you had seen the mothering style
exhibited in my house right at the time I was preparing this talk, you would
have seen for yourself that I am really a fraud. Emerging from my hiding place
in front of the computer, I was appalled to discover the way my 4 year old had
extended her water play to include the toilet bowl. Moving on to the kitchen, I
was even more unhappy to find that the 8 year old had met with an unfortunate
accident heating something sticky and sugary in the microwave. And the rest of
the kitchen didn’t make me any more pleased, because the 12 year old and her
friends had done some cooking, and appeared to have used every single dish we
owned. Taking one look at the place, I asked the children if they wouldn’t mind
leaving me for a moment to take stock of the situation. Perhaps a better parent
than me would have celebrated these obvious sings of creativity. But, in fact, I
yelled, “Outside! The whole lot of you!’
Such is the
example of detachment parenting that I confess to practising on a bad day, in
truth, fairly regularly inside the privacy of my own home. (and I hope none of
my neighbours are here.) And the occasional all too public displays I sometimes
am prone to on a bad day outside my home- let’s say in the isles of Pac n Save.
Pac n Save is one of the best places to do some field observations, and compare
notes. In fact, most of us observe and make judgements, if we are honest, on the
parenting we witness here.
I recently
observed the shopping challenges of one particular woman with two pre-school
children. Her trolley was full to bursting and the pained look of desperation
was one I recognised having had myself on many occasions. “Please, please let me
make it down these last two aisles,” I heard her praying fervently as she plied
her charges with biscuits –gasp- not yet paid for, enduring the dirty looks of
the holier than thou, obviously barren/virginal women co-shoppers. Down the
next aisle I spotted them again. The two year old was now standing in the cart,
probably flattening the bread and squishing the bananas, tossing out the
biscuits under the wheels of the cart, and the three year old was crawling,
commando- style, along the filthy floor. Later, as I loaded my groceries
into my car, I noticed this same woman buckling the two-year-old into a car not
too far away from mine. I considered walking over to congratulate her on making
it through the ordeal, when I heard a terrible noise coming from back in the
store’s entranceway. It was the three-year-old, who was loudly voicing his
disapproval at being abandoned there. The mother went on unpacking, no doubt
thinking to herself, “Call CYPS, see if I care.”
These stories
illustrate the problems of talking about attachment that I certainly face as I
give this talk today. None of us is perfect, and we all have our varying degrees
of baggage we carry around about this subject. If you are like me, you cart
around an entire trolley of baggage. It’s awfully hard to face the idea
that our parents didn’t parent us the way they should have and even harder to
think that we are not as good at parenthood as we might be. We all have opinions
as to the right way we should parent (our way, on our good days) and the flaws
of others are so glaringly obvious as we pass judgement.
But having said
all that, I am here to talk about attachment today. You have just
learned that I am a mother, and in my spare time, I work as an obstetrician and
gynaecologist in the hospital up the hill.
So from an
obstetrician’s perspective, when does attachment begin? Attachment really
begins about 7 days after conception. About two days earlier, on the fifth
day, the embryo reached the uterine wall and began the process of imbedding
itself into the velvety soft blanket of endometruim that lines the uterus. By
the next day, day 6, it had sent down its roots, the beginnings of the placenta
or whenua, its little patch of earth. Like a world within a world. It is 7
days after conception that the embryo finally sets up that first critically
vital link since losing contact with the mother ship, more specifically, the
ovary from where the egg was launched. It is of critical importance because
failure to establish the connection will mean the embryo’s certain death. About
a week after departure, as the embryo implants, it sends into the mother’s
bloodstream a chemical messenger. This is the hormone human chorionic
gonadotrophin, or βhcg. There is pretty well only one place βhcg comes from,
which is why it’s so handy in pregnancy tests. When the ovary detects the
presence of βhcg in the mother’s blood, it increases the production of the
hormone progesterone. And ovarian progesterone is needed to stabilise the lining
of the uterus- it acts almost like gelatine, as it sort of “sets” the
endometrium into a semi-solid state until the developing embryo can make this
hormone for him or herself. If there is any miscommunication, between what
amounts to a menage a trois between the embryo, ovary and uterine lining,
the level of progesterone falls and the lining becomes unstable; runny and
liquid. And if that happens, the embryo will be washed away in a tide of
menstrual flow. Better luck next time.
Now you may think
I’ve got it wrong. That I’ve confused this physical attachment with
psychological attachment. Certainly, from a psychologist’s perspective,
attachment is defined a little differently .To a psychologist, attachment is the
capacity of the mind to form selective and enduring bonds. Since Bowlby wrote
The Nature of the Child’s Tie to his Mother in 1958, hundreds of experiments
have been undertaken to demonstrate the physiological and behavioural aspects of
secure and insecure attachment. At the heart of attachment theory is the idea
that that the human infant is programmed to relate to others from birth. The
relationships that form with primary others are paramount in shaping the psychic
development of the child (Bowlby, 1958). Any witness of childbirth would
certainly agree there is often a psychic magic when a mother greets her baby in
those initial moments. The programming that lays the foundation for this,
however, happens long before. The groundwork for attachment begins even before
we develop a mind, way before consciousness begins. The severing of the
umbilical cord is not when attachment begins, though it can certainly mark the
end, or perhaps the beginning of attachment disorders. Seven days after
conception, for each one of us in this room, this hormonal connection between
our bodies and our mother’s bodies was really the day we “went live” as we
established a connection to the server. And the connection was established with
hormones. Ah, hormones.
I believe I didn’t
mention my 15-year-old son in the introduction to my talk. Well, let me tell
you, I do know hormones. They are certainly strange and wonderful things. And
every once in a while, in the privacy of my own home, I watch helplessly as they
rage out of control. Hormones are, as I’ve just told you in the story of embryo
implantation, chemical messengers. They modify the body’s environment and its
chemistry. They are a way of our body communicating messages, sometimes quite
powerful messages, that regulate and control how we develop, how our bodies
function and sometimes, how we behave.
Consider the
stimulus and response of behavioural psychology. Consider further, the powerful
and classical example of the stimulus of the tiger about to crouch, spring and
then devour you as you saunter through the jungle in search of your next meal.
What is the most appropriate response? Your mind and your body quickly decides,
and releases hormones; cortisol, ADH and adrenalin. It’s adrenalin that causes
your heart rate to speed up. The blood supply increases to your muscles. You are
able to run faster to escape the threat of danger.
Scientists are now
becoming aware of the neurobiological differences between genders to the classic
fight or flight example of stimulus and response. Although responses can be
classically conditioned, as Pavlov found with his dogs, the response to any
given stimulus is by no means chiselled in stone. This is because in between
seeing the stimulus and making a response, there is an all-important gap. In
this gap we decide, consciously or unconsciously what to do. For some animals,
the response they make may mean the difference between the survival and
extinction of an entire species. So they must choose carefully. The response
may seem like a no-brainer, wouldn’t everyone run from the threat of danger?
But, maybe not. Unlike their male counterparts, neither flight nor fight may be
the best option for a new mother when faced with a stressful or dangerous
stimulus. The primary goal may be to protect. After giving birth, the
psychological attachment, the mother’s tie to her young, may mean the difference
between their life or death. Whether we women chose to fight or flight, or the
alternative, to tend and befriend, may literally depend on our hormones. And
the hormone that makes the difference here is one that new breastfeeding mothers
have in abundance. It is oxytocin.
Oxytocin has got
to be the favourite hormone of obstetricians. It is involved in childbirth,
causing the uterus to contract. Huge amounts are released into the maternal and
umbilical circulation just at the moment of birth. It causes the milk letdown,
the reflex that causes milk to be ejected from the breast. And I’ll bet
oxytocin is your favourite hormone too. Oxytocin is not called the love hormone
for nothing. It is released in large amounts at orgasm. Oxytocin is responsible
for creating bonds; between lovers, mothers and babies, and within families.
Oxytocin has the power to reduce anxiety states, take away stress, and relieve
addiction. It aids in relaxation and feelings of calm. Massaging and stroking
the skin releases oxytocin, particularly on the ventral surfaces. In fact, if it
feels good, oxytocin is probably involved. Oxytocin is present in one form
or another in just about every species. That’s because, in the animal kingdom
there is often a fine line between what is food and what is family. It is
believed that the extremely high levels of an oxytocin-like peptide present in
the bloodstream of a shark that has just given birth, prevents her from turning
around and consuming her young. And maybe that’s as maternal as a shark can get.
As a mother of a teenager and a soon to be teenager, I can identify with that.
The importance of
oxytocin in establishing relationships has been studied extensively by Professor
Tim Insell and his team. They used the model provided by two different species
of vole, a tiny mouse like creature. Prairie voles and Montaine voles may look
very similar on the outside but like the Town mouse and the Country mouse, the
similarity stops there. Their social behaviour differs dramatically. The refined
and cultured, town-like Prairie voles are the “moral minority” of the rodent
world. The males form lasting pair bonds, remaining loyal to the same female
“until death do us part” after their first mating. They are the very models of
social respectability. The females are wonderful mothers, nurturing their young
and weaning them late. The fathers actively participate in parenting. And the
children hang around the nest long after they are weaned. It’s all very
civilized.
On the other hand,
the country vole, or Montaine, has a rougher, darker nature. Montaine males are
irresponsible cads. With a love ‘em and leave ‘em mentality, they have as many
conquests as they can. And they have nothing to do with their offspring. Even
the females are terrible mothers. They feed their young for a minimum of time
and kick them out of the nest as soon as they can. While researching the voles,
Professor Insel found marked differences in the positioning of oxytocin and
dopamine receptors within an area of their brains called the “nucleus accumbens”,
one of the pleasure centres of the brain. It appeared that the prairie vole’s
brains were wired to find attachments pleasurable.
Sadly, oxytocin
injections are not all that is needed to change bad dads into doting fathers, or
improve the maternal instincts of mothers like the one I told you about earlier
in Pac n Save. Unfortunately it’s not that simple. There are three
possible reasons for this. One is that in order for a hormone to work, you also
need its receptors to be present. Another is that the half-life of oxytocin is
also very short…only a few minutes long. The third reason is that these
experiments were done with intracerebral oxytocin. An intravenous or
intramuscular injection of oxytocin is unable to cross a very important obstacle
known as the blood brain barrier. And so, in order to ensure our partner’s
fidelity, we would need to have their medial amygdala’s cannulated by a
neurosurgeon under general anaesthetic, which is hardly practical.
But recently,
scientists at the University of Zurich showed us that perhaps all hope is not
lost. A clever way of circumventing the unpalatable idea of neurosurgery is the
use of oxytocin nasal spray. As drug addicts the world over have always been
aware, snorting is a very effective way of getting a drug into your
intravascular system. That’s because the roof of the nose is lined with a
plexus of veins – and you all will be aware of that if you’ve had a nosebleed.
And just above that plexus- is the brain. So there you have it, the
neurobiology of the head rush. When subjects were given oxytocin in the
form of nasal spray, and then asked in an experiment to lend money to strangers-
those who were given the real thing and not a placebo were far more generous and
trusting. Of course, the worry is that this sort of shady dealing will be taken
up by every used car salesperson and con artist on the planet. And of
course it more than explains why sex sells. The memory of oxytocin release
imprinted on the medial amygdala of the brain becomes associated with the
advertised product- you feel good and suddenly you find yourself craving the
most unnecessary of items.
The thing that
most surprised the Swiss researchers was that the experiment worked despite the
first two conditions, the short half life and the lack of receptors- But it
makes sense when you realise that just like our tiger-fearing ancestors, we must
have some capacity to react quickly to changes in our hormonal system…. Just
imagine if we have a bit more time, the length of an entire labour for
example….and a whole lot more oxytocin…what happens is this:
After
physiological birth, mothers and babies are primed to fall in love. The
receptors on their brains are occupied by powerful substances, so addictive that
they’d be regulated under the Controlled Substances Act if commercially
available. The endorphins and oxytocin released in the process of birth set the
neurological stage for us mothers and our babies to be addicted to each other,
to crave each other’s skin. The brain scans of those falling in love mirror
those addicted to cocaine. Love is a form of addiction. The behavioural
manifestations of hormones can be seen when a mother is left virtually
unattended after birth. When she is left to follow her own instincts, she will
pick up her child and place him, ventral skin to ventral, skin overtop of her
heart. And left to his own devices, a baby will attach himself to his mother’s
breast. And this just serves to fuel the addiction, as more oxytocin is
released. It’s in the programming. In the hardware. Mother Nature’s plan. This
ability that women have to bond with their babies and to form attachments has
parallels in other animals. We have enough dairy farming in the Waikato for many
of us to know that you must beat those cows away from their calves with a
shovel. These bonds are strong
It was Konrad
Lorenz who first advanced the concept of imprinting. For this work, he won a
Nobel Prize for medicine in 1973. Imprinting is the process that causes newly
hatched birds to become rapidly and strongly attached to the first thing they
see, usually the mother bird, but sometimes, a parental surrogate, or for the
purposes of experiment… any number of weird and wonderful things. Infant birds,
like all infants, will show evidence of distress when this attachment figure is
removed from them. Scientists measure what they call the proximity of the young
animal to the “imprinting target” as an index of the strength of the bonding. In
birds, there are critical periods for imprinting to occur and there are probably
critical periods in humans too. An example of this is illustrated by a study
comparing mothers who were given their babies right after birth, to a group of
mothers whose babies were taken straight away for what at that time was standard
nursery care. This first group of mothers were much less likely to leave their
infants in a separate room when seen again in follow up. That there might be
windows of time where bonding is optimized is not to say that attachment cannot
form throughout the lifespan, and in various and unconventional ways. The route
to parenthood is not always through your own flesh and blood.
But it might be
harder for some. We know that children who are deprived of social contact in the
first couple of years of their lives may go on to become some of societies most
troubled adults…such a history of depravation is almost pathognomonic of violent
criminals. The brain, powered by the flow of electrical activity analogous
to computer circuits, processes information through the flow of electricity.
These neural circuits may be sensory, motor, emotional or cognitive. Every
experience we have, climbing a tree, eating a strawberry, blowing a kiss,
excites certain neural circuits and leaves others inactive. Those that are
consistently turned on over time will be strengthened, while those that are
rarely used may be dropped away. One of the great laws of neurology is "Cells
that fire together, wire together." But a second great law is: use it or lose
it. Unused neural circuits are gradually eliminated, which is also
referred to as "pruning," This pruning streamlines children's neural processing,
making the remaining circuits work more quickly and efficiently. Without
synaptic pruning, children wouldn't be able to walk, talk, or even see properly.
Over time we lose the ability to make the connections…a good example is language
acquisition, which is much easier when we are young. And maybe some of us do
lose the ability to connect to each other, although I think it just becomes
harder.
Can any of this
complex behaviour actually be pre-wired? This is the essence of the nature
versus nurture debate. Is it our genes or is it our environment that
determines who we become? This picture of a tiger that was raised by a sow shows
that the way we are raised, the nurture part, does have a critical importance as
to who we ultimately become. And so Freud was right about mothers. Motherhood
counts. But life before we are born, in the world within a world, matters
more than we might think. A complicated example follows so please bear with me.
I promise, it is clear in the end. An experiment was done on two species of rat
that differed quite profoundly in the way they behave. Let’s call them type A
and type B. And for the purpose of the discussion, I’m going to exaggerate the
behaviour differences to make them more obvious. Here goes:
Type A rats when
put on a white board, huddle in the middle and don’t move. Type B Rats dart all
over the place.
Type A rats behave
in a certain way when put into a maze. Again, Type B rats behave quite
differently.
Lastly Type A rats
can swim, and Type B rats, cannot swim.
In this experiment
sperm and eggs of both types of rats were obtained, and then Type A and B rats
were made in a test tube. They were then placed back in the uteruses (uteri?) of
each type, and their opposite. When born, the baby rats were fostered out to
type A and B mothers, and again to their opposites. Confused? Well, maybe the
question I’m about to ask will help make it clearer to you: What do you think
was more important in determining the ultimate behaviour of the rat, that is,
whether it behaved like a type A rat, or like a type B rat?
Was it the sperm
and egg that it came from, whether its genes were
type A or type B? In other words, nature?
Was it the mother
that raised it from birth, a type A role model or a type B role model? In other
words, nurture?
Or was it
something else, whether it was implanted into a type A uterus or a type B
uterus?
The answer is
perhaps a surprise. It’s the uterus that counts.
When the human
genome project was completed scientists were also surprised. In fact, they were
frankly shocked. Apparently we are made up of a mere few thousand genes, unlike
the millions previously thought, befitting the status of such a highly evolved
animal. Even more alarming, is that we hardly differ at all, maybe by 1%,
genetically speaking, between apes, our closest ancestor.
So, it seems that
what we will be; a man or a mouse, and how we behave; like the Town Mouse or the
Country Mouse, depends not only on what genes we have, but how they are turned
on, and when. It is thus not so much nature versus nurture as nature via
nurture. And one thing we know is that to turn on the genes for love we must
experience love ourselves.
Do we experience
love in the womb? Perhaps this is true for some of us. Genes for behaviour can
get turned when we are still in utero, but some apparently get turned on even
sooner! In studies of attachment, one of the most powerful predictors of
“attachment style” comes from the attachment style experienced by the child’s
own mother. In other words, how the mother herself was mothered. So not only
does motherhood count, grandmother (or grandfather!) hood counts.
How can we go back
and change this? Should we give up now, since we can’t change our pasts? Of
course not. Because attachment continues throughout the lifespan. And that is
because the human being has an astounding capacity to love. There is one other
source of oxytocin I haven’t talked about yet. Let’s go back to the developing
embryo and fast forward another 3 weeks in time. It’s about now, just 4 short
weeks into the life of the embryo that we could pick up with a very sensitive
ultrasound scan the first beatings of the fetal heart. The heart is the first
organ to develop and become functional. Each individual cell of the heart
or myocardial cell is capable of beating in its own rhythm. Individual cells
will do this all by themselves; they have what has been called a pacemaker
function. Myocardial cells have the ability to pace each other- to synchronise
their rhythms. Two myocardial cells in a dish beside each other will beat with
their own unique tempo, but put them together so they touch and the rhythm will
be exactly the same. Within the mother’s body, the fetal heart senses
hers. Their heart rates are not exactly the same; the fetal rate is much higher.
But there is still synchrony to their rhythms. The fetus detects her mother’s
anxiety, anger, and joy. They communicate with each other, a chemical mixture
of hormones, sometimes love.
The patterns of
synchrony can be illustrated when both the fetal heart rate and maternal heart
rate are monitored. I have with me, and want to show you now, the fetal heart
rate tracing, or in obstetrician-speak, the CTG, of Sarah Booth, whose mother
Donna underwent an emergency caesarean section at 33 weeks into her pregnancy.
When Donna arrived at the hospital she tried to remain calm. But then, things
changed. Donna was bleeding, and an emergency caesarean section was required to
save both of their lives. Donna was terrified, about many things; she was
worried about her own physical health and about her little girl, Sarah, who she
had already named and felt strongly bonded and connected to. She was most
terrified about having a general anaesthetic and what this would mean, which in
her mind meant being separated from Sarah. This fear caused a large amount of
adrenalin to be released into her body. Sarah felt the surge of her mother’s
adrenalin going through her body and her heart rate soared, adding 40 beats per
minute extra to the normal rate. “ What’s wrong, Mom? Are we going to run?” But
neither flight nor fight was an option. This level of tachycardia is part
of what is called, in classic obstetrician-speak, a “non-reassuring” heart rate
pattern. By the criteria defined by the Royal College of Obstetricians, it
indicates the possibility of fetal distress. One real possibility was that Sarah
was bleeding too. But she wasn’t. The fetal distress seen on this monitoring was
the effects of maternal distress. It was a baby’s fear of her mother’s fear. It
is a visual representation of an empathetic connection that an unborn baby had
for her mother.
For me, as an
observer, it was a way to see that attachment between babies and mothers can
occur long before they are born, although in this case the birth happened only a
few minutes later. By the time the cord was cut, a bond had already been
formed. These are the bonds that are reinforced every single day, consciously or
unconsciously, ready or not, beyond the first week of pregnancy by hormones.
These chemical signals regulate the baby’s internal rhythms in tune and attuned
to her mother’s, so they are not separate individuals but in many ways they are
one. They are attached by bonds that can become independent of a physical
connection.
In our newborn
units we see that when mothers are allowed to stay with their babies they gain
weight, stabilise their vital signs, grow and thrive…their very survival
improves. Somehow this magic improves their clinical outcome. The finding that
mothers at the bedside have more impact on their babies’ health than many modern
technological interventions have spurred on a movement in many countries to keep
mothers and babies together even in the most intensive care settings.
Attachment works in mysterious ways. It is easy to find examples.
When it goes wrong
we have stories like the ones from Romanian orphanages- full of children- some
orphaned and some simply abandoned. Many have disabilities and a background of
abuse before they even reach the institutions. The lack of human contact,
stimulation and caring almost always leads to developmental delay, and as adults
even psyochopathy. Where mental illnesses already exists loving human contact
can make all the difference. As one Mental Health rights activist put it, “One
thing we know for sure from decades of international work on disability rights
is that institutions are terrible places for the mentally ill’…and I would add,
and even the mentally well.
When it goes right
we have stories like this. When an Australian hospital stopped its policy
of routinely admitting its Methadone babies to the new born unit, they were
surprised at the outstanding outcomes. These irritable, miserable and
withdrawing babies needed lots of care- in the form of TLC. The mothers
were encouraged to provide that care themselves, on the regular post partum
ward. This was a new policy, because normally these babies were admitted to the
new born unit. So, instead of having trained (actually, over-trained)
newborn unit nurses providing medical care, mothers provided love, and staff
provided support. And because these babies need extra love and support- they are
in fact on the extreme side of high need -the hospital introduced an army of
volunteer “grandmas” for these babies. For one thing, the other mothers
thought it was such a wonderful idea they wondered how they could qualify for
grandmothers of their own. Breastfeeding rates improved dramatically- in a
group of mothers where traditionally the rates have been extremely poor. In the
follow up 6 months down the track. not only did breastfeeding rates continue to
be above the national average. but the number of babies in CYPS care at 6 months
declined remarkably too. And I find it amazing to note that that none of the
babies “uplifted” were breastfed babies.
It is easy to find
examples. It’s the explanation, the why, that scientists have trouble with
sometimes. There are still so many unanswered questions. Are there genes
for attraction, attatchment or good mothering? Can we give mothers credit for
their good mothering, or is it prewired already? How and when are those genes
turned on? How can we foster attachment between mothers and babies, and
ultimately between each other? What is the key to attachment? But that is
one question I would argue that all of you know the answer to already.
Most people
believe that the heart has something to do with love. Poets over centuries have
written about it. Before research found hormones, those with no understanding
of CTG monitoring, attachment theories, medical or psychology degrees or any
knowledge of biochemistry and pharmacology could tell you, the heart is involved
in falling in love. They feel it, inside. Right here. Maybe, they are right.
Because, every single chamber of the heart is capable of making oxytocin. The
right atrium, felt to contain the overall pacemaker of the heart, has the
richest supply. When we fall in love maybe our hearts release this. The way we
look and act towards our children releases it in theirs. And so, magic things
happen that cannot be so easily and scientifically explained. There is a
powerful connection between mothers and their babies; they provide energy and
support to one another. This magic somehow improves babies’ clinical outcomes,
in some cases, their very survival, and their ability to attach to their own
children one day. Much can be attributed to the power of love. Listen to what
another obstetrician hero of mine says. He is Leboyer, who wrote Birth without
Violence. He is talking about how should we touch a newborn baby.
What should our
hands say? Exactly what the mother and her womb have been saying….The womb that
pressed slowly, tenderly. The womb that embraced. The womb that was source of
love….Without rediscovering this visceral slowness that lovers find
instinctively, it is impossible to communicate with the child.
But, people will say, “you
are making love to the child". Yes, almost.
I would like to
suggest that on some level we all know that visceral slowness that beats within
us, that rhythm lovers find. Because body language, the language of skin to
skin, is really our native tongue., Because our hearts were formed within the
world within the world, we have learned to respond to the heart of another. We
do not lose that ability. But sometimes we forget.
References:
Bowlby, J. (1958),
The nature of the child’s tie to his mother. International Journal of
Psycho-Analysis, XXXIX, 1-23.
Leboyer, F. 1975.
Birth Without Violence. Williams Collins Sons and Co, Glascow. 103pp.
Ridley, Matt.
2003. Nature via Nurture: Genes, Experience and What Makes us Human
Fourth Estate,ISBN
1-84115-745-7.
© Alison Barrett
2005 This article may be copied and used without further permission on the
condition that it is not used in any context in which the WHO International Code
of Marketing of Breast-milk Substitutes is violated.
Last week there was an interesting program shown on
SBS Television in Sydney. It was the story of a woman who was born
with two wombs, two cervix and two vaginas, who conceived in each
uterus at the same time.
Being born with two complete reproductive systems
is extremely rare and is often associated with infertility. However,
despite the odds, this mother became pregnant, with one baby a girl
and the other a boy. The pregnancy was carefully monitored by her
obstetrician (this was in the UK), because each uterus was about
half the normal size and there was concern that this may hamper the
baby’s growth and development.
The film followed the mother through her
pregnancy, interviewing her and her husband, the obstetrician and
her mother. There were several scares when ultrasound scans
suggested there may be problems (once it was the shape of one baby’s
head) but these proved to be false, and the babies grew well. The
plan was to maintain the pregnancy as long as possible, with a
caesarean birth scheduled around 36 weeks.
By 34 weeks, the scans were being done every two
weeks to determine growth. At the 34 week visit, the obstetrician
announced that the fluid surrounding one baby was reduced and he
scheduled an immediate caesarean, for later that day. The poor
mother was very upset, and not at all emotionally ready to give
birth, however she agreed for the sake of her babies. Given that
very few cases of a double pregnancy like this have ever been
recorded, and none had produced two live babies, it is easy to see
how everyone was trying to achieve a positive outcome in this case.
The scene after the caesarean was heartbreaking.
The mother was shown in a bed, sobbing because she had not seen her
babies. They had been whisked away in theatre to be cared for in
intensive care as both had respiratory distress (a typical problem
of premature births) and after two days, she had still not seen her
children. She was bereft and clearly distressed by this separation,
which had started suddenly, out of the blue on a day when she
thought she was going to have a routine check-up.
Finally, after a long wait, she was taken in a
wheelchair to the ICU where she was helped to cuddle her babies
against her skin, while a midwife helped with all the tubes etc. The
change in her was dramatic - at last she held her precious bundles
and expressed the joy of holding her child and what it meant to her.
While this was an interesting story, and no doubt
one of great historical interest, I felt it showed some glaring
inadequacies in the system at the hospital in Exeter. Why was the
mother left for two days without even seeing her babies? She was
quite well and there was no apparent reason why she couldn’t have
been taken immediately she left recovery, to at least see her
babies. To deprive a mother, especially in her special
circumstances, of the opportunity to affirm her babies were OK,
after all the concern raised by this complex pregnancy, seems cruel
and unusual punishment.
A caesarean birth is not one that most women
anticipate, yet sometimes they are necessary. When a caesarean is
indicated, especially in an emergency, why can’t basic humanity
prevail and steps be taken to minimise the trauma that will
accompany such an event? There are many things that can be done to
ensure the emotional and psychological well being of the mother and
her family at that time: holding the baby in theatre, having skin to
skin contact while in the recovery area (and early breastfeeding),
unrestricted access to the neonatal intensive care unit and help
with expressing colostrum for the baby. The needs of the father must
also be considered as he is often traumatised as well, and he needs
unrestricted access to his partner and baby too.
On another note, I was surprised that the
obstetrician made the snap decision for an immediate caesarean based
on one reading of a scan that suggested some reduction in the
amniotic fluid surrounding one baby. Surely the appropriate course
would have been to monitor the situation, taking readings every two
days to ensure that the fluid was decreasing. A single
interpretation of a scan may have been incorrect, or it may have
indicated reduced fluid that was stable and not a cause for concern.
I couldn’t help wondering if his rushed decision had something to do
with the theatre schedule, and the presence of the TV crew that day.
The babies were as well as could be expected at 34 weeks and
respiratory distress (the result of being born too soon) was
reported as their only problem. Why couldn’t they have stay safely
inside until both they and their mother were ready to take the next
step into the world?
Maternity Facility staff in New Zealand are
now aware of the Baby Friendly Hospital Initiative (BFHI) which was created by
UNICEF and the World Health Organisation to encourage the protection, support
and promotion of breastfeeding (WHO 1989). The criteria for a Baby Friendly
Hospital apply to all countries and to all health care facilities and passing
the Ten Steps to Successful Breastfeeding is necessary to meet the minimum
standard of the BFHI. There has
been some criticism of the terminology ‘Baby Friendly’ as for some people it
is not clear whether this means ‘Mother Friendly’ also. It is interesting
how a culture has been constructed where we can even imagine that the needs of
the baby and the mother are either separate or at odds with each other. This
article may not on the surface appear to be related to my usual topic of
feeding/breastfeeding but it is very pertinent. How can breastfeeding be
successful unless the mother is present to respond to all baby feeding cues and
to foster the mother/baby relationship? A recent paper (Kanitz et al 2004)
looking at the effects on piglets isolated intermittently from their mothers,
showed decreased behavioural activity, and studies in rodents and monkeys show
progressive lethargy and passive patterns of behaviour in isolated infants (
Hennessy et al 2001). Sleepy unresponsive babies who are slow to establish
breastfeeding are the norm in neonatal intensive care units. Is this always due
to prematurity and anaemia as is usually suggested, or does separation play a
bigger role than we realise?
Within neonatal intensive care environments
the mother baby dyad needs protecting not only to foster breastfeeding, but to
avoid or reduce psychological/emotional trauma in both baby and mother.
Separation is a difficult situation for a mother and baby and for a NICU to
become mother and baby friendly this separation should be minimised as much as
possible.
A baby/mother friendly initiative that many
will not be aware of is the one created by Professor Adick Levin who heads the
neonatal unit at Tallinn Children’s Hospital in Estonia. The holistic,
humanistic approach used in this unit is considered to ‘represent a truly
baby-friendly hospital’ (Levin 1994). Levin expresses concern about the BFHI
accreditation and states ‘A paradoxical situation has been created: the
routines of the maternity wards are in accordance with the BFHI, whereas a
neonatal intensive care unit in the same hospital does not have to meet the
requirements of the BFHI’ (Levin 1999). Levin sees the ‘Ten Steps for
Successful Breastfeeding’ as being inadequate for sick and preterm newborns
and has developed eleven steps for the improvement of psychosocial and medical
care. Kennell (1999) when commenting on Levin’s innovative care in Acta
Paediatrica states ‘ hopefully these ideas will stimulate all neonatologists
to review critically their policies for parents and siblings’.
Dr Heideliese Als developed the
relationship based, developmentally supportive approach for newborn intensive
care (NIDCAP). Many Western NICUs are now providing a developmentally supportive
environment for their babies but are they protecting the parent infant bond and
reducing separation as much as possible? In one recent ongoing research study in
a unit which has implemented developmental care, the loss of the mothering role
has been identified as the main stressor for mothers with babies in intensive
care (Spencer 2003). Keeping mothers and babies together in our current medical
and political climate is a difficult undertaking. Current medical thinking does
not support non-separation as yet and certainly the health care dollar is not
going in this direction. Certain private medical facilities in the United States
are providing neonatal intensive care spaces with parents room attached but
there is yet no signs of this happening in New Zealand and in fact there are
some disturbing signs that rooming in beds are actually being reduced.
Westrup, Kleberg & Stjernqvist (1999)
point out that even NIDCAP has not been implemented generally to date as yet.
Westrup et al speculate on the reasons why NIDCAP has not been implemented and
discuss the difficulties of evaluating the effects of interventions involving
caregiving. They point out that it is difficult to achieve an optimal
experimental design for caregiving evaluation and state ‘ Furthermore it is
ironic that NIDCAP, a fairly benign intervention that in essence simply provides
more humane care, should be subject to tighter scrutiny than many other probably
far more questionable interventions. The more ‘heroic’ interventions such as
high frequency ventilation, inhaled nitric oxide and extracorporeal membrane
oxygenation were all widely used prior to well controlled trials demonstrating
their efficacy and safety’ ( Westrup et al 1999). For units who have now
implemented NIDCAP it is hard to believe that we ever did anything else. I
imagine that it is hard to look back on past practice without a little shudder
of horror. What will we be having little shudders about in twenty years? Westrup
et al conclude their article with an evaluation of the care given in many NICUs
and suggest that this caregiving tends to be more task or procedural based and
that NIDCAP requires a shift to a process guided and relationship based model.
They state ‘ We have observed this change to be challenging to people
especially to those whose identity is largely tied to scientific and
technological competence’.
Professor Levin works with the concept of
maintaining the psychological umbilical
cord which represents the social and emotional bond between the mother and baby
(Levin 1994). This psychological umbilical cord forms during pregnancy and
becomes increasingly important during the early months of life and must remain
intact throughout the child’s developing years (ibid). The neonatal unit
developed in Tallinn is based on principles designed to maintain the integrity
of this psychological umbilical cord. Levin’s hypothesis is that the care
given in most Western neonatal intensive care units increases the risks of
neonatal morbidity and decreases the opportunity for development of positive
parent–infant attachments (ibid). This Western model is characterised by the
baby having contact with a frequently changing medical and nursing staff and
little contact with parents. Levin sees maternal care of the baby as having many
advantages for the baby including better weight gain, fewer infections and
improved social and psychological development. For the mother the advantages are
a more rapid physical recovery, development of confidence in her ability to
mother the child and development of a strong attachment (ibid).
Step eight of the principles for family
centred neonatal care (Harrison 1993) suggests that ‘parents should be
encouraged to assume non-medical aspects of their baby’s care’ and should be
‘encouraged to room in with their child before discharge until they are
comfortable with all important aspects of their child’s care’. The
‘care’ implied in this step is physical care including such things as nappy
changing, bathing and feeding. All important aspects of care of course but
limited in concept. The psychological and emotional needs of the baby, mother
and family need attention long before the potential few days of rooming in prior
to discharge. Harrison’s work is otherwise commendable and the ten principles
developed in consultation with parents are a positive step forward. However they
do not go as far as may be necessary when family centred care is the goal.
In contrast to the principles of family
centred care Levin’s steps (Levin 1999) for the improvement of psychosocial
and medical care in units for sick newborns start with ‘The mother should be
able to stay with her sick newborn for 24 hours a day’. Step four is ‘The
psychological stress of the mothers should be decreased during the whole
treatment period’, and step ten is ‘The mother and the infant should be
considered as a closed psychosomatic system. Everyday ward rounds should focus
not only on the infant but also on the needs of the mothers’. The steps also
promote breastmilk feeding and skin to skin contact between the mother and baby
as much as possible. Although Levin acknowledges the promotion of breastfeeding
is an important goal he states that it is only one component of a truly baby
friendly environment and that the psychological tie between the mother and the
infant should be maintained.
Levin proposes that the high technology
used in neonatal intensive care units needs to combine with humane care to
create a truly baby friendly culture. The steps proposed by Levin would
certainly foster an environment more conducive to breastfeeding establishment
and success and very much in keeping with the goals of the WHO/UNICEF Baby
Friendly Hospital Initiative. If more contact between mother and baby not only
encouraged more awake babies, more efficient feeding and a stable milk supply,
but also fostered psychological and emotional well- being in the mother and the
baby, then perhaps we need to look again at some of our NICU ‘belief
systems’, particularly around the concept of minimal handling. What is
inappropriate contact? I suggest that there are not many instances when
prolonged contact between mother and baby is inappropriate yet sometimes mothers
report cuddles being terminated so that the baby can be put back into the
incubator ‘for a rest’. Research indicates that babies are more
physiologically stable when having skin to skin contact with their mothers than
they are when resident in incubators (Ludington-Hoe et al 1999, Anderson 1991,
Feldman et al, Charpak et al 2001). There are also maternal reports of babies
not being ‘allowed out’ for a cuddle because they have had ‘big days’
(blood tests, X rays etc). A baby who has had a traumatic day must surely
benefit from contact with her/his mother and the combination of the smell, touch
and sound of the mother must surely be remedial and restorative and in such a
situation highly desirable? Although we are not in a situation as yet where we
can offer 24 hour contact between mothers and babies in intensive care units
there are some steps that can be implemented to improve the situation. The most
important start is reflection on practice and a reconsideration of care
priorities. Does the cuddle need terminating and why? Is it better for the baby
to have the mother’s familiar and secure somatosensory envelopment than to be
inside an incubator? Is it really a problem to briefly ‘disturb’ a baby to
have cuddles with the mother when the baby is likely anyway to fall back into a
restful sleep again immediately when settled on her/his mother? Lets think again
and in the words of our very own developmental care promoter, Sarah Priday –
‘ it’s about being thoughtful and not thoughtless and careful instead of
careless’.
References
Anderson G. C. (1991). Current Knowledge
About Skin to Skin (Kangaroo) care for Preterm Infants.
Journal of Perinatology, X1, (3), 216-226.
Charpak N., Ruiz-Pelaez J.G., Figueroa de C
Z., & Charpak Y. (2001). A Randomised Controlled Trial of Kangaroo Mother
Care: Results of Follow Up at 1 Year of Corrected Age,
Pediatrics, 108, (5), 1072-1079.
Feldman R., Eidelman A.I., Sirota L., &
Weller A. (2002). Comparison of Skin to Skin (Kangaroo) and Traditional Care:
Parenting Outcomes and Preterm Development.
Pediatrics,
110, (1).
Harrison H. (1993). The Principles for
Family-Centred Neonatal Care. Pediatrics.
92, (5), 643-650.
Hennessy M.B., Deak T., & Schirml-Webb.
(2001) Stress-induced sickness behaviours: an alternative hypothesis for
responses during maternal separation. Developmental
Psychobiology, 39, 76-83.
Kanitz E., Tuchscherer M., Puppe B.,
Tuchscherer A., & Stabenow B. (2004). Consequences of repeated early
isolation in domestic piglets (Sus scrofa)
on their behavioural, neuroendocrine and immunological responses.
Brain,
Behaviour and Immunity, 18 (1), 35-45.
Kennell J.H. (1999). The Humane Neonatal
Care Initiative. Acta Paediatrica 88,
(4), 367-370.
Levin A. (1994). The Mother-Infant Unit at
Tallinn Children’s Hospital, Estonia: A Truly Baby- Friendly Unit.
Birth
(21) March.
Levin A. (1999). Humane Neonatal Care
Initiative. Acta Paediatrica 88. (4),
353-355.
Ludington-Hoe S.M., Anderson G.A., &
Hollingsead A. (1999). Birth-Related Fatigue in 34-36 Week Preterm Neonates:
Rapid Recovery With Very Early Kangaroo (skin to skin) Care.
Journal
of Obstetric, Gynecologic, and Neonatal Nursing, 28, (1), 94-103.
Spencer C. (2003-2004) Ongoing unpublished
research.
Westrup B., Kleberg A., & Stjernqvist
K. (1999). The Humane Neonatal Care Initiative and family-centred supportive
care. Acta Paediatrica 88, (4),
1051-1052.
World Health Organisation/UNICEF. (1989)
Protecting, Promoting and Supporting Breastfeeding: The Special Role of
Maternity Services. A Joint WHO/UNICEF
Statement. Geneva.
Independent Nurse
Educator, Paediatric, Neonatal, Adult and Plunket Nurse – one who teaches
about family centred care. Is there any other way to deliver care?
I worked with Carol
Bartle (the previous speaker) for a long time on the Chch Neonatal Unit (NNU) -
perhaps another dissident – I’m not sure but like Carol I am one who is
passionate and determined to make a difference – a fighter for the families
and the babies. I teach about Family
Centre Developmentally Supportive Care (FCSC) for babies and parents – I want
to achieve optimum outcomes developmentally for the baby and emotionally for
all. Developmentally supportive care tries to give the parents what they’ve
been promised – being with their new family member - to stay with their baby.
Admittance to a NNU and
the journey experienced therein has lifelong repercussions. Parents will
revisit their memories of the NNU – let’s make them good memories. Here are some examples of
what I teach:
-
Parents
are not visitors
-
Expressing
breast milk by bedside should be encouraged – to remain with your baby
-
Never
move a baby’s cot/incubator without telling parents
-
If
a baby who is constipated poos – ring the parents – if overnight phone
them in the morning before leaving to share the good news rather than just
letting them read it in on the chart
-
1st
bath should always be done by the parents
-
Empower?
– never take power away in the first place -
-
Staff
should never refer to an infant in their care as ‘my’ baby – the baby
always will be the parent’s baby.
-
Imagine
you are taking your baby to be immunized – the practice nurse is ready to
immunise your baby.. Do you let her have your child and wait in the waiting
room, do you go with your child and chat to the nurse as she immunizes or
are you there supporting your child whilst the nurse immunises your child? I
suspect the last scenario – why is the same respect not shown to premature
babies and their parents?
Mother-baby separation in
NICU? Why are we having this discussion? The proponent of Supportive Care, Prof
Heidi Als to whom we all refer and revere has always advocated mother/baby
togetherness – single family rooms in NNUs.
The good news is that
they are happening in the US and what’s more surprise, surprise not only are
parents happier emotionally but drug errors and infection rates are reduced. So
never mind the humanitarian side of this initiative the finances make sense too.
The initial large expenditure is recouped quickly and administrators/hospital
boards are happy. Incidentally kangaroo
care, where the parent holds the baby skin to skin which is practiced throughout
NZ doesn’t get a look in some small crowded NNUs in the UK – perhaps we’re
not doing so badly after all.
www.prematurity.org
www.preemie-1.org
www.pregnancy.org
www.tabs.org.nz
(Traumatic birth web site)
Here’s a window into
the NNU environment for you to reflect on: - the emotional intricacies and day
to day realities that parents face - complex and ever-challenging journey of
parenting a premature infant: these are quotes from parents:
-
I
feel responsible for the situation but powerless to do anything to change
the situation.
-
This
is a new, traumatic form of parenthood
-
‘Yes,
this is crazy but I’m not’
-
“when
they wheeled him out of the delivery room, it felt as if they were tearing
off a piece of me as they left”
-
“it
seemed to me as if I was abandoning her”
-
‘It
hurt having to see Alison in the hospital and watch others taking care of
her. That was supposed to be my job. I almost felt as if she were not even
my baby – as if I was just her babysitter, going in to hold her every once
in a while”
-
my
body must recover without a baby in my arms
-
The
forced separation from my baby only intensified my emptiness, detachment,
and denial.
-
I
felt Guilt at leaving, guilt at staying.
Everyone’s’ no 1
priority in the NICU is discovering and meeting babies medical needs and to get
babies home as soon as possible – I’m not making excuses but no one goes
into the health profession to make money – we have to begin with the fact that
everyone is doing their best and when it seems that it is less than that, that
it is unwitting on their part.
So take heart hospitals
are beginning to realize that instead of requiring families to adjust to the
NICU, the NICU should adjust to families. This is the movement NNUs aspire to -
known as FCDSC – the state of the art NICU policy and practice involves
parents and encourages them to remain close to their babies. There finally is a
realization of what parents knew all along - that medical technology is
important for premmies, but so is nurturing and a parent’s touch and presence.
Take heart and good luck.
Click
here to view Carol's powerpoint presentation
Be faithful in small things
because it is in them that your strength lies. ~Mother
Teresa
People
often argue that the little stuff doesn’t matter. The details of how you
respond to your baby’s cries, hunger, sleep, happiness or distress are often
replaced by schedules, schemes and strategies aimed at getting life under
control and back to ‘normal.’ Instead of listening to our babies and
following their cues, we panic and look outward for advice. Despite popular
belief, babies do indeed come with instruction manuals. They’re encoded
with them. The question is: can you read the one you’ve been given? All
parents, regardless of how in tune and aware, sometimes need the outside
assistance of family, friends or professionals. But it’s the little stuff
that’s actually most important and is sadly often overlooked.
All
difficult things have their origin in that which is easy, and great things
in that which is small. ~Lao Tzu
Amazing new research with premature babies in Boston, Massachusetts, USA now
offers us big reasons to rethink the value of those supposedly little
things. Premature infants are at risk for multiple developmental, cognitive
and physical difficulties as they grow and age. In the past, this risk was
attributed solely to their premature status and viewed as intractable.
However, these babies in Boston are disproving this belief and showing us
how early experience can alter the very structure of a brain.
Do not think that love, in
order to be genuine, has to be extraordinary. What we need is to love
without getting tired. ~Mother
Teresa
For
any new baby, leaving the rich, nurturing and perfectly attuned environment
of the womb is stressful. For premature babies whose under-developed
nervous system already leaves them with fewer resources for managing life in
the outside world, birth is made even more traumatic by invasive procedures,
bright lights, loud noises, cold sterile environments and separations from
mother. Dr. Heidelise Als, Associate Professor of Psychology at Harvard
Medical School, works at Children’s Hospital in Boston and developed an
intervention called Newborn Individualized Developmental Care and Assessment
Program (NIDCAP).
NIDCAP
is changing the culture of newborn care and enriching the health and
development of babies along the way. Developmental specialists work with
hospital staff and parents to help them recognize, understand and react to
the signals of their babies. Nurses and parents alike are taught to see
babies as active participants in their own care, responding to their cues
just as with other kinds of communication or language. In other words, they
are learning to read their instruction manuals. Parents are not restricted
to particular visiting hours and are encouraged to hold their babies with as
much skin-to-skin contact as possible, especially during stressful
procedures. Big comfortable reclining chairs are provided so parents can be
with their babies at all time, even in sleep. Parents are also assisted to
create a personalized, private, calm environment in their child’s incubator
area to create a soothing oasis in the middle of the noisy hospital.
Great
things are done by a series of small things brought together. ~Vincent Van
Gogh
So
what’s the amazing part? The findings show notable and dramatic differences
in brain structure and development. The premature babies who participated
in the NIDCAP program were identical to the control group. They ranged from
28 to 33 weeks gestational age and had similar levels of health and family
health status. The only difference is that the NIDCAP group received
the intervention until the age of 2 weeks (adjusted for prematurity).
At 2
weeks and then again at 9 months of age, all babies underwent
neurobehavioral, electrophysiological and magnetic resonance imaging (MRI)
testing to assess brain development and neurological structure. At both
measurement points, babies in the NIDCAP group had substantially better
results, evidencing healthier levels of emotional regulation, motor quality,
and cognitive functioning. The babies were more relaxed and responsive
than their control group counterparts and their brains where better
organized and contained more white matter, the material needed for learning,
thinking and decision-making. They also showed better connections in areas
that control senses like vision. By nine months of age, these babies showed
remarkable differences in their abilities to hold crayons, grab and
manipulate objects and crawl, all predictors of future cognitive
functioning.
Miracles are a retelling in small letters of the very same story which is
written across the whole world in letters too large for some of us to see.
~ C. S. Lewis
Dr.
Als’ research is continuing. She is now doing more long-term studies and
looking at the impact of the NIDCAP program on these babies as they age.
Thus far the trend continues through age 1 and preliminary data from the 8
year olds indicates the same results. By old standards, her results are
nothing short of miraculous. Many people still resist her thinking, despite
ample evidence that the quality and philosophy of care for babies makes such
a huge difference. Nonetheless, research like this helps highlight the
force of early experience and the influence of seemingly small details.
After all, it is not just premature babies who are vulnerable to stress or
who have critical periods of brain development. Most everyone now
acknowledges the crucial importance of the first years of life. Dr. Als’
data helps to spell it out in ways we can both understand and implement.
Anyone
who doesn't take truth seriously in small matters cannot be trusted in large
ones either. ~Albert Einstein
This
research emphasizes the significance of early relationships and how the
nuanced and almost imperceptible differences in response can mean the
difference between health and handicap. All these babies had equal and
excellent medical care. The differences in their brains – and ultimately
their emotions, thoughts and abilities – arose from interactions and
relationships. To many in the world, whether a baby is held, how a baby is
fed or where a baby sleeps is believed to have little impact on future
wellbeing. Things that can’t be counted or measured, like how well a baby
is nurtured, are often dismissed. What NIDCAP has done is measure the
immeasurable, linking the warmth and responsiveness of early experience to
quantifiable outcomes. Instead of an event to be managed or a problem to be
solved, these fortunate babies were treated as people to be acknowledged,
known and engaged with. They needed nurturing and connection. In meeting
their needs, which are the needs all babies share, they flourished in a way
that was previously unheard of. This work has direct implications for the
choices and challenges of home, hospital and society at large. When we
follow the wisdom and compassion offered by this science, we work toward the
true potential of our children. In small things we place our faith. From
small things greatness can grow.
