Mother and Child Reunion - Kangaroo Mother Care Must Become a Standard and Routine Part of Optimal Maternity Care

by Jacqueline Levine, LCCE, FACCE, CD(DONA), CLC, BA,     

Dr. Lennart Righard's seminal study¹, published in the Lancet in 1990, gave rise to his famous video, "Delivery Self Attachment"², that illustrates parts of his extraordinary research.  It shows babies who, when left undisturbed on their mothers' bodies immediately after birth, find the breast by themselves; they crawl to it, or scrabble about to find it, use the feel of the breast on their cheeks and chins to orient themselves as they search about for that “sweet spot”…then they latch and suckle with competence. When front-to-front and skin-to-skin after birth, a newborn responds with hard-wired behaviors that promote healthy maturation of brain and body. The video also observes babies whose abilities are either impaired or negated because of exposure to intrapartum meds, separation from their mothers after birth, or both.

Lennart’s own poignant words adorn the packaging of his video: “Newborns have a great need for love, which makes a separation between mother and child most unfortunate”³. (Emphasis mine.) A banner below that quote, set in 16-point type and caps, proclaims "THIS SIX MINUTE VIDEO WILL CHANGE PROTOCOLS!"

It is indeed "unfortunate" that so many mothers and their newborns still experience the consequences of resistance to or ignorance of this best-evidence protocol. Hospital staff and caregivers still swoop in and whisk newborns away after just a few minutes of time with their mothers for routine procedures, processing and/or observation.   As with so many entrenched maternity-care practices, the protocols that Righard thought would certainly change are still in place, even as evidence for keeping mother and baby together continuously mounts.  

There’s another aspect of a new parent’s birth experience with her newborn that needs to be promoted and admired, something rarely mentioned, rarely talked about by OBs, and rarely discussed as part of the normal and natural part of understanding the newborn; the remarkable abilities and competence of that newborn.  Birthing of the placenta gets more coverage in birth literature than do the stellar capacities of a new baby.

The aforementioned Righard video of newborn behavior amazes because we see the antithesis of what first-time mothers imagine that their infants will be like.  Popular images show a greasy-eyed newborn, wrapped up and be-blanketed as tight as a little dumpling, handed over to mom to hold in arms. The Righard video causes gasps at the first images of that lively newborn pushing its little legs against its mother's abdomen, bobbing its head with power and purpose, and performing the initial latch with brio.  Mothers need to be told that, even if they have had intrapartum medications, they must continually give their newborns the opportunity to perform as they are hard-wired to do, and we must emphasize that newborns are capable and competent, and Kangaroo Mother Care enhances that competency.  

Body-to-body contact, front-to-front, is the newborn’s normal physiological expectation, supporting the maturation of brain and body both.  Without actually calling it “Kangaroo Mother Care” the AAP recommends that babies stay on mother’s body, “skin-to-skin” (S2S) to help maintain healthy regulation of vital signs in the first hours after birth⁴. Any understanding of newborn physiology acknowledges the imperative of keeping newborns on mother’s bodies for long stretches, so babies may make the physical adjustments for healthy beginnings of life outside the mother.

 Mothers have always needed to keep their babies with them, and supporting evidence for that urgent desire has been around for quite a while.   With the understanding of what is best for the health of the newborn, the WHO and UNICEF very specifically and unequivocally advise that mothers and infants remain together 24 hours a day and launched the Baby Friendly Hospital Initiative in 1991, which, while meant to support breast feeding, also supports skin-to-skin, if not specifically “Kangaroo-ing”.  Sadly, we can count only about 500 hospitals in the whole of the United States with the BFHI designation; only one in six birthing places in our country is Baby Friendly! ⁵

Kangaroo Care, "a universally and biologically sound method of care for all newborns," ⁶ incorporating S2S, breastfeeding and support of mother and baby, has become a standard of care in many NICUs.  Wikipedia represents that fully 82% of NICUs in the US practice KMC, and while there’s no citation to back up statistic, it’s not surprising, given the wealth of studies going all the way back to 1979 that show how effectively KMC helps at-risk babies, i.e., improving and normalizing vital signs, stabilizing breathing and heart rate and regularizing glucose and stress levels.

 While the acknowledged benefits of Kangaroo Mother Care (KMC) arise from the classic examples in the studies done with preemies, there’s abundant evidence that every baby requires and surely deserves to spend ample and uninterrupted time front-to-front and S2S. The conclusion of one recent study notes that “birth kangaroo care was integrated into routine delivery room care, with nurses noting no change in nursing workload.” ⁷ Hope-giving news!

 In 2016 an article in Medpage Today, described some hugely impactful long-term benefits that KMC confers: “‘A 20-year follow-up study on “kangaroo care”, a multifaceted intervention for low birth weight infants and their parents centered on close physical contact, found that it led to significant long-term protective benefits. First-year benefits of kangaroo mother care on IQ…were still present after 20 years, wrote Nathalie Charpak, MD, Fundacion Canguro de Colombia in Bogota, and colleagues, online in Pediatrics. The results pointed to other benefits including significantly better scores for school absenteeism and aggressiveness during follow-up.’ This study indicates that kangaroo mother care had significant, long-lasting social and behavioral protective effects 20 years after the intervention.”⁸ Despite recommendations from the medical community and studies proving the long-lasting efficacy of this “intervention”, and still babies and mothers are still parted and best-evidence is ignored.

 Some state Departments of Health have got it right, and officially recommend skin-to-skin. The DOH in Ohio distributes cards for its WIC program that read, in part:  " ‘Hold me, Mom.’ Babies who are held skin-to-skin on their mother's chest right after birth are happier and less likely to cry, are more likely to latch on and [sic] breastfeeding well, have better heart rates, have better temperatures than under a warmer, have better blood sugars, burn less [sic]  calories than under a warmer. So, be sure to tell your doctor and the hospital nurses that you want to hold your baby for at least the first hour after the birth, skin-to-skin (baby naked, not wrapped in a blanket). That's the best way to introduce your baby to the world’ ⁹. (Emphasis mine.)

How can we account for the fact that a mother is advised by a government agency to "be sure" to tell her doc and staff to give her this aspect of best-evidence care? Why must birthing people be advised and exhorted to ask for, or demand, treatment that should be just pro forma in every LDR? Must precious energy and focus during labor be diverted to advocate for best-evidence care, when that kind of care should just be expectations met? Even for this well-documented and uncomplicated course of action, we cannot count on our caregivers to act reliably in the interests of mother and baby.  Must mothers be warned not to allow their newborns to be taken away from them for at least an hour?

How amazed we are to find out  that benefits of KMC extend far into the lifetime of babies, but every parent–to-be should know about the  immediate positive advantages that KMC confers… advantages that parents want for their children: Kangaroo-ed babies have been shown to have significantly higher scores in visual and auditory maturation, in alertness, “cuddliness”, self quieting,  abilities to pay attention, good state regulation,  and higher scores at 6 months on the Infant Temperament Questionnaire than babies who had standard care.¹⁰   Is it such a stretch to extrapolate that those happy benefits would extend to term or normative birth-weight babies and that full-term healthy newborns need to be on their mothers’ bodies just as acutely as  babies in the NICU?

 In 1979, the renowned obstetrician and perinatologist Michel Odent proposed, under the aegis of his Primal Research Center, in an article on human ecology, and that the natural ecology  for an infant is to be S2S with the mother. The Human Ecolog deals with "primal" health, a branch of epidemiology that brings together studies exploring correlations between what happens during the primal period (fetal life, perinatal period and the year following birth) and what occurs later in life in terms of health and personality traits. The treatment of mother and newborn as an inseparable dyad is the basis for those studies and can be found compiled in the Primal Health Research Database. ¹¹

There are some fascinating studies about interactions between mother and baby immediately after birth that investigate the "smellscape" of mother's breast: the effects of odor on neonatal arousal, oral and visual responses".¹² Here are just a couple of  observations from a multitude of studies available: "volatile compounds originating in areolar secretions or milk release mouthing, stimulate eye-opening and delay and reduce crying in newborns".^{13 "}The odor of human milk is more attractive to human newborns than formula milk, independent of postnatal feeding experience."¹⁴

The skin-to-skin interactions between mother and babe are maturational for newborns; the contact stimulates the vagus nerve, causing increased digestion and absorption in the newborn gut. Nancy Mohrbacher, author and breastfeeding expert, in her article "Rethinking Swaddling" ¹⁵ has pointed out the differences between the infant held skin-to-skin and those who were wrapped and held by their mothers.  She cites studies showing that swaddling delays the first breastfeed and leads to less effective suckling, greater weight loss, and more jaundice. Routine swaddling has negative effects on the infant whether in the hospital or at home. Mothers need this information before their babies are born. This knowledge confers the power to insist on evidence –based care for themselves and their newborns.

The Lamaze Healthy Birth Practice #6 ¹⁶ addresses a mother's time in the hospital, to promote behavior that is really just a prelude to how mother and baby should proceed together when they go home. There is a “dose relationship” ¹⁷ of S2S-time with breastfeeding success during those first days after birth in the hospital, but parents will soon take their babies home of course, and where is the advice from caregivers that continuation of S2S is as vital on day 7 or day 27 as in the first minutes and hours of a newborn’s life?  Every parent deserves the information that S2S is a normal way to care for babies; every parent deserves to have this information before their babies are born, so they may advocate for this best-evidence care, and every baby deserves to spend time on a parent’s body.  Will caregivers tell parents-to-be what they need to know? Can we really wait for the slow grind of the universe of medical planets to align properly for all the studies to be heeded and for textbooks and training and institutions to change? How long until it becomes standard medical protocol to advise every new parent that S2S is a vital a part of daily ongoing newborn care to promote an infant’s healthy future?