UMEÅ UNIVERSITY MEDICAL DISSERTATIONS

New Series

no 20

From the Departments of Paediatrics and Child Psychiatry,

University of Umeå, UMEÅ, Sweden

NEONATAL CARE ROUTINES

Influences on maternal and infant behaviour
and on breast feeding

by

PETER DE CHATEAU

Umeå Universitet
Umeå 1976
 NEONATAL CARE ROUTINES
Influences on maternal and infant behaviour and
on breast feeding

AKADEMISK AVHANDLING
som med vederbörligt tillstånd av Rektorsämbetet
vid Umeå Universitet för avläggande av medicine
doktorsexamen kommer att offentligen försvaras i
Samhällsvetarhuset,sal D, måndagen den17maj1976
kl. 09.00

av

PETER DE CHATEAU
med lic.

Umeå 1976
 UMEÀ UNIVERSITY MEDICAL DISSERTATIONS
New Series
no 20

From the Departments of Paediatrics and Child Psychiatry,

University of Umeå, UMEÅ, Sweden

NEONATAL CARE ROUTINES

Influences on maternal and infant behaviour
and on breast feeding

•»y

PETER DE CHATEAU

Umeå Universitet
Umeå 1976
To Viveca, Maarten, Mikaela and Simon

The studies were supported by research grants from the

Åhlén Foundation, Semper Research Fund on Breast Feeding,
Findus and the Medical Faculty, University of Umeä.

Printed In Sweden
KB Affärstryck, offset, Umeå 1976
This thesis is based on the following communications which will

be referred to in the text by their Roman numerals:

I. de Chateau, P., Holmberg, H., Jakobsson, K. and Winberg, J.:

Lactation promoting and inhibiting factors in neonatal care.

II. de Chateau, P., Holmberg, H. and Winberg, J.: Left-side

preference in holding and carrying newborn infants. I. Mothers

holding and carrying during the first week of life.

III. de Chateau, P. and Andersson. Y.: Left-side preference in

holding and carrying newborn infants. II.Doll-holding and

carrying from 2 to 16 years.

IV. de Chateau, P. and Wiberg, B.: Long-term effect on mother-

infant behaviour of extra contact during the first hour post

partum . I. First observations at 36 hours.

Acta Paediatrica Scandinavica: Accepted for publication

V. de Chateau, P. and Wiberg, B.: Long-term effect on mother-

infant behaviour of extra contact during the first hour post

partum. II. Follow-up at three months.

Acta Paediatrica Scandinavica: Accepted for publication

VI. Armelius, K., Cajander, K., de Chateau, P. and Lindberg, A.:

Parent-infant relationship during the neonatal period.

A p ilot study describing parents perception of contact with

their sick infants.

CONTENTS

1. GENERAL SUMMARY page 6

2. THE IMPORTANCE OF TH E NEONATAL PERIOD 11

2.1 Animal studies 12

2.2 Human studies 15

2.2.1 Maternal behaviour 15

2.2.2 Parity 17

2.2.3 Caretaker environment 17

2.2.4 Disadvantages at birth 19

2.2.5 Feeding 20

2.2.6 Sex of infant 21

2.2.7 Infant capacities 22

2.2.8 Infant soothability 24

2.2.9 Early stimulation of infant 25

2.2.10 Conclusion 27

3. AIM OF THE PRESENT STUDY 28

4. METHODS 29

4.1 Direct observations 29

4.2 Interviews and questionnaires 30

4.3 Scrutiny of antenatal, hospital and

Child Health Centre records 31
 RESULTS page 32

5.1 Influence of neonatal care on breast

feeding (I + IV) 32

5.2 Holding and carrying newborn infants

(II + III) 34

5.3 Extra contact during the first hour post

partum ( IV+ V) 36

5.4 Parents' perception of contact with their

sick newborn infants (VI) 38

6. INTERPRETATIONS 40

ACKNOWLEDGEMENTS 43

REFERENCES 45
 - 6 -

GENERAL SUMMARY

The studies on which the present thesis is based started during

practical day-to-day routine work on the delivery floor and in

the maternity and neonatal wards. We were impressed by the fact

that newly delivered mothers, both with healthy and sick newborn

infants, very often expressed feelings about numerous problems

and difficulties connected with childbirth and the newborn baby.

Many of these problems were of a non-physical nature and had

often to do with existing routines and practices in child rearing.

The general attitudes of the hospital staff seemed of special

importance to the mother's situation.

Our studies were from the start practical and aimed at examining

whether changes in customary care procedures could influence the

mother and infant relationship and the baby's physical and psycho­

logical development.

The following factors were therefore studied:

1. The influence on the duration of breast feeding of hospital

routine care such as weighing the infant before and after breast

feeding combined with supplementary feeding and the giving of

information and support to mothers and to fathers.

2. Many routines such as weighing, bathing, dressing, Credé's

profylaxis immediately after birth, have come between a natural

 - 7 -

close contact between mother and infant. The care of mothers

and infants after delivery has become more and more artificial

We studied therefore how a naked skin to skin contact and

suckling contact during the first hour post partum, given

before these routines, influenced maternal and infant behaviour

and lactation.

3. On the fifth day after delivery parents perception of their

contact with sick newborn babies was investigated by means of

a questionnaire.

4. The way a mother holds and carries her infant during the first

week of life was compared for mothers who had healthy infants

and had not been separated from them and mothers whose infants

were unwell and who had been separated from them.

5. Non-separated mothers who h eld their infants to the right were

studied with their infants three years later.

6. Since adult males and females hold and carry infants differently

the development of this behaviour during childhood was studied.

The following observations can be suggested from our studies:

1. Routine weighing of infants before and after every breast

feeding followed by supplementary formula intake during the

 - 8 -

first week post partum, is associated with a high frequency

of early failures in breast feeding.

2. The giving of information on breast feeding to mother and

father together the first week after delivery is associated

with a more succesful breast feeding.

3. Mothers who h ave had an immediate post partum naked skin to

skin and suckling contact ("extra contact") with their infants,

breast-feed them considerably longer.

4. During the neonatal week left-handed and right-handed mothers

hold their healthy infants in 80 per cent of all cases to the

left with close body contact, while separated mothers (with

sick infants or risk infants under observation) hold them signi­

ficantly less often to the left and with less body contact.

5. During the neonatal period mothers can carry their infants to

the left, "in the hands" or to the right. A much higher propor­

tion of primi parous mothers with "extra contact" carry their

infant to the left as compared with those mothers receiving

routine care, while any tendency to carry "in the hands" dis­

appears.

6. Right-holding non-separated mothers during a three year follow-

up period show more need for contact with Child Health Centres,
 - 9 -

than left-holding ones, even when the children in both groups

are equally healthy.

7. The preference for holding on the left develops during childhood,

children under six years of age have no side preference in holding,

after six left-side preference increases with age. Girls in all

ages studied (2-16 years) are ahead of boys in developing this

preference for holding on the left. This sex difference seems to

persist in adult life. The development of carrying shows a similar

pattern.

8. Primiparae and multiparae given routine care after delivery behave

differently during breast feeding at 36 hours. An extra naked skin

to skin and suckling contact with their infants given to primi -

parae immediately following delivery eliminates this difference.

9. Primiparae with "extra contact" and routine care behave differently

not only at 36 hours, but also at three months. For example mothers

with "extra contact" spend more time looking en face and kissing

their infants.

10. Infants of primiparous mothers with "extra contact" show d ifferences

in behaviour when compared with those with routine care. This is

especially so at three months. For example infants with "extra con­

tact" are smiling more often and crying less frequently than those

with routine care.

 - 10 -

11. The sex of the infant seems an important determinant of both

maternal and infant behaviour. Differences in behaviour asso­

ciated with sex of infants within the same care groups occur

both at 36 hours and three months. "Extra contact" seems to

influence boys and their mothers more than girls and their

mothers.

12. The severity of the infants illness, the mode of delivery and

the by the mothers reported time from delivery to first touch

of infant seems to influence the mothers feelings for the in­

fant on the fifth day. The material is however insufficient

to decide whether the time to first touching the infant or the

severity of the infant's illness determines the difference in

the perceived relationship with the infant. Fathers seem to

have more difficulties in relating to their sick infants than

mothers during the neonatal period.

13. Categorical conclusions from the foregoing should be avoided.

Families have a great range of individual needs, backgrounds

and capacities. Flexibility to the individual requirements of

each and every family is therefore needed. Specific care routines

during the neonatal period might be beneficial to one family,

although deleterious to another. To label some interactive patterns

as "good" and others as "bad" is more than speculative; evidence

is still lacking and the impact on the growing infant-parent rela­

tionship has still to be settled.

 - 11 -

2. THE IMPORTANCE OF TH E NEONATAL PERIOD

During the last decades maternal and infant morbidity and mortality

have been reduced to a very low level. Hospital personal has been

focused upon providing a high quality of physical care, both for the

mother and her infant, but little active interest has been directed

towards the importance of the neonatal period for the development of

the unique mother-father-infant relationship. Many routines in our

neonatal and maternity wards, such as separation (1, 36), were in­

troduced to prevent infections and to improve treatment of the new­

born, and while the adverse influences on mother-infant relationship

were recognised (47, 48) many mothers today are still not allowed to

touch, hold and care for their newborn premature or sick infants. If

the period immediately following delivery is a particularly sensitive

one (35) many changes in our day-to-day care and hospital practices

have to be made to ensure that mother and infant remain togethêr during

this period.

A number of factors influence the growth and development of the newborn

infant as well as maternal behaviour during this first period. Pitkin

et al (63) and Smith( 79) have described the influence of maternal nutri­

tion on the foetus and infant. The use of drugs during pregnancy (71)

and the perinatal period (13, 15) can bring about disadvantages for

mother and infant. Obstetric complications and prematurity are found

more often in the history of children with behaviour disorders than in

controls (94). Maternal behaviour is influenced by a multitude of factors

 - 12 -

as described by Bowlby (11). Still others can be added (see Table I),

and certainly many unknown factors also contribute to the final pattern

of maternal behaviour. Nilsson (60) in his studies of paranatal emotio­

nal adjustment of healthy women found that psychiatric symptoms during

the post partum period, to a greater extent than such symptoms during

pregnancy, are connected with conflicts in the reproductive function,

i.e. conflicts between demands of reproduction and ambivalent attitudes

towards childbirth. Mothers, who during pregnancy had experienced a

large number of crises and who w ere unable to solve their problems be­

fore delivery, experienced great difficulties in their adaptation

towards the initial needs, both biological and psychological, of their

newborn infant (45, 46).

2.1 Animal studies

Several animal species have been studied during the neonatal period

in an attempt to identify specific maternal caretaking behaviour.

Studies of variations in neonatal care and their possible impact

upon development of the offspring and behaviour as adults have given

further evidence of the special importance of the early post partum

period.

A short separation of goat mothers and their young can lead to

deviant maternal behaviour (40), whereas a five minute contact

between the goat mother and her own or alien young immediately
 - 13 -

Table I

Some factors affecting maternal and infant behaviour.

Genetic background

Cultural background

Mothers relation to her parents

Relation to infants father

Education

Occupation

Health

Obstetrical history

Pregnancy

Parity

Del ivery

Postnatal adaptation and postnatal care

Infant's sex

Infant's state

Infant's development

Infant's age

after birth results in the normal accepting and caretaking behaviour

of the mother. Hersher et al (28, 2.9) demonstrated in the goat and

sheep that separation reduces the mother's feeding and caretaking

ability in about 50 per cent of the animals studied. In rats a short

 - 14 -

Separation of mother and infant in the neonatal period has been shown to

alter maternal caretaking upon reunion of mother and litter (70).

The quality and quantity of sensory stimulation during the neonatal

period seems to be of special importance to the infant's normal deve­

lopment and maternal behaviour. Harlow et al (26) have shown that

after two weeks of tactile deprivation of their infants, rhesus-monkey

mothers who we re allowed see and hear, but not to touch them, spent

less time viewing these infants. The same authors (25, 27) also demon­

strated that contact clinging is the primary variable that binds the

mother to her infant and infant to the mother. Infant monkeys were

placed together with wire and cloth mother-substitutes, both equivalent

as providers of milk, but not equivalent as providers of tactile or

psychological stimulation. The infant monkeys spent significantly more

time with the cloth mother-substitutes and clung to the cloth mother-

substitutes more often in a frightening or strange situation. These

infant monkeys, deprived from tactile contact with their own m others,

failed, when gr own up, to rear their own young normally.

Denenberg (20), in studies on the rat, has shown that the way of hand­

ling the infant during infancy has wide and profound effects upon its

behaviour and physiology in adulthood. Likewise Levine (49, 50) has

pointed out that handled rats show more adaptive responses to stress

than non-handled ones, and that stimulated rats grow more rapidly,
 - 15 -

given the same amount of food as controls, and, using a conditional

avoidance as a criterion of learning ability, learn more quickly.

The consequences of handling (gentle cutaneous stimulation in early

infancy) seem to be of more importance where emotional factors are

concerned, than in matters of cognitive function (50).

2.2 Human studies

2.2.1 Maternal behaviour

In a number of studies Klaus et al (34, 35, 36, 37, 38, 68) have

questioned whether or not present hospital practices may effect

later maternal behaviour and have given evidence that the immediate

post partum period is especially sensitive for the development of

the mother-infant relationship. Twelve mothers (37) with healthy

full-term infants were filmed during their first contact and an

orderly progression of tactile contact was observed in all mothers.

The mothers started with fingertip touch of the infant's extremities,

followed by palm contact on the trunk, encompassing of the infant and

eye-to-eye contact. Mothers of normal premature infants followed a

similar sequence of behaviour, but at a much slower rate. In another

study (38) 14 mothers (control group) had the usual routine contact

with their healthy full-term infants after delivery and 14 mothers

(extended contact) were given their naked babies for one hour within

the first three hours after birth and also fiven extra hours of contact
 - 16 -

each afternoon of the three days after delivery. In follow-up studies

one month (38), one year (34) and two years (68) after delivery

differences were found in maternal attachment behaviour and linguistic

behaviour between the extended contact and control group.

The importance of direct eye-to-eye contact as a possible releaser of

positive maternal feelings has been suggested by Robson (69); Moss and

Robson (59) found a positive correlation between positive maternal

attitudes towards infants during pregnancy and frequency of face to

face contact between mother and infant during a home visit one month

after birth. At three months however, this correlation was statisti­

cally significant only for girls and their mothers, no longer for

boys. Both Rubin (72) and Klaus (37) have pointed out the importance

of the development of exploratory touch in the newly - delivered

mothers. Maternal touch and holding are involved in the progressive

handling pattern of the human m other with her newborn baby. Sal k

(73, 74, 75) and Weiland (90) found that 80 per cent of the mothers

held their infants to a point to the left of the body midline. In

explaining this left side preference in holding infants Salk (74)

discussed the influence of the maternal heartbeat as an imprinting

stimulant that has a soothing effect on the infant. Presenting the

normal heartbeat constantly during the first days of life to newborn

babies, Salk (73) demonstrated a significant increase in weight

gain. Palmquist (62) could not corroborate the effect of the normal

human heartbeat sound on weight development of normal healthy infants.

Weiland and Sperber (91) postulated that the preference for left­

side holding primarily serves to relieve anxiety in the adult

carrier.

2.2.2 Parity

Maternal parity may greatly influence the mother-infant interaction

during the first week. Thoman et al (84) found that multiparous

mothers appear to be more sensitive than primi parous mothers tö

the cues of their infants. Infants of multiparae sucked more during

breast feeding and consumed more during bottle feeding, even though

primiparae spent more time in feeding their infants and stimulated

them more to get them to suck. In another study (81) primiparae were

found to be more attentive to their infants, but had more difficulty

in quietening them. Second mothers responded to infant crying more

quickly and more often by feeding than first mothers did (5). No

differences were found in attempts to achieve visual contact at first

contact with their full-term healthy newborn infants between multi­

parae and primiparae (37).

2.2.3 Caretaker environment.

The facilities for mothers and infants may differ greatly during their

hospital stay. Rooming-in has long ago proved to be very useful in the

prevention of childhood behaviour disorders (32). Rooming-in provides

 - 18 -

a natural mother-child experience under supervision of maternity

personnel and facilitates instruction of mothers and fathers in

infant care (18). First mothers rooming-in with their newborn babies

judged themselves, one day prior to discharge, to be more confident

and competent in baby care and thought that they would need less

help in caring for their infants at home (23). Rooming-in mothers

also claimed to understand the attributes of their baby's cry in a

better way than control mothers did. During the hospital stay rooming-

in mothers have shown a higher incidence of breast feeding (33) and

in the first two months at home a higher percentage of weaning by

control mothers has been reported (52). The importance for the father

of a rooming-in hospital practice has been discussed by Lind (54).

Burns et al (16), in a study of infants given up by their mothers for

adoptive placement, investigated the effects of multiple and single

caretakers during the first ten days on infant distress during feeding.

Being cared for by several persons and fixed feeding schedules in the

maternity ward resulted in relatively many distress symptoms, such as

grimacing, turning away from the nipple, fussing and crying. Less in­

fant distress in feeding was found when this rigid schedule was changed

to a more individualized one. When a single caretaker treatment was

given first to another group of infants, these infants showed an in­

crease in distress when they were switched to the rigid schedule at

10 days. These studies illustrate that infants react to the kind of

care they receive and that the sequence of environments (maternity

ward - rooming-in and vice versa) influences these reactions. Rooming-

in, which is more like the home situation after discharge, and being
 - 19 -

cared for by only one person (the mother) may therefore be of great

importance for the development of mother-infant synchrony.

2.2.4 Disadvantages at birth

In a study of neonatal separation Barnett et al (1) allowed a group

of mothers to enter the premature nursery from the second day after

birth and to touch or handle their premature infants in the incubator.

As compared with mothers without this extra contact mothers in this

study group showed greater commitment to their infants, more confi­

dence in their ability to mother the infant, more skill in taking

care of it, and provided the infant with more stimulation. Leifer

et al (48) found differences in maternal attachment behaviour (smiling

and close body contact) between mothers of full-term infants and

mothers of pre-term infants. In the same study no differences were

demonstrated in maternal behaviour between mothers of premature in­

fants who had only visual contact and those who had experienced a

nearly full sensory contact during their infant's 3-12 weeks hospita­

lization. However, the incidence of divorce and adoption sometime

after hospital discharge was much higher in the visual contact group.

Lower maternal self-confidence (77) was found in primi parous mothers

separated for 3-12 weeks from their premature infants as compared

with primiparous mothers permitted physical interaction and contact

during this period. This difference was not found in multiparous

mothers. In a retrospective study Stern (39, 80) found a strong corre­

lation between prematurity along with separation and child abuse.

 - 20 -

In a carefully controlled prospective study of 670 infants Werner

et al (92) found evidence that if the infant is at some disadvantage

at birth - in their study perinatal asphyxia - poor environmental

circumstances reinforce the disadvantage already existing, while

favourable postnatal social influences can compensate for it.

2.2.5 Feeding

Experiences during feeding in the neonatal period may be of special

importance; events in the very first feeding of an infant can affect

many subsequent feedings (24).

Thoman et al (81, 82, 83, 84) in a series of observations concerning

parity of mother, mode of nutrition, breast feeding versus bottle

feeding, and sex of infant found evidence that the relationships

observed during the first days of contact between mother and infant

may be indicative of subsequent parent-child relationships and signi­

ficant for development and personality characteristics of the child.

Richards and Bernal (4, 5) reported that breast-fed and bottle-fed

infants may differ at birth. Breast-fed infants are fed for longer

periods and cry more than bottle-fed infants right from the start

and have a different pattern of interaction with their mothers during

the first days of their lives. Differences in infant behaviour found

on the eighth day can be seen as the result of both or either of these

two influences, in combination with the nature and quantity of the

 - 21 -

nutriment received. Infant behaviour and development may thus be

influenced by early feeding experience. At the time of discharge

the attitude of the nursing staff can influence a mother's decision

whether to breast feed her child or not (67, 77), rooming-in may

have a positive influence on the duration of breast feeding (52)

and hospital practice may subsequently influence infant behaviour

and later development.

2.2.6 Sex of infant.

Leiderman et al (47) found no differences in maternal self-confidence

between mothers with male and mothers with female infants. Maternal

behaviour was different depending on sex of infant one week post

discharge, mothers with girls showed more ventral contact, although

boys and girls were held equally much. At three weeks of age boys

experienced a more extensive and stimulating interaction with their

mothers than girls did (58). Lewis (51) demonstrated differences in

maternal holding and vocalizing between mothers with boys and girls

at three months, by two years, however, there were no sex differences.

This illustrates the change of maternal behaviour over time and is a

complication in the study of mother-infant behaviour (51). The change

in interaction between mother and infant over time has been discussed

by Hinde (30); the mother-infant relationship is dynamic and each

interaction may a ffect subsequent ones and the course of the relation­

ship. Thoman et al (83) found that during breast feeding two days post

partum primiparae mothers talk more to their female infants and that
 - 22 -

the duration of breast feeding and amount of vocalization at

two days are positively correlated.

2.2.7 Infant capacitites

The individual reactive capacity of the newborn baby and his

influence on the environment has been shown in a number of studies.

Bowl by (10, 11) states that infant smiling, crying, clinging, suck­

ling and following are activities that may release and facilitate

maternal behaviour, which is involved in attachment and maternal

care. Although Richards (65) is critical of Bowlby's explanation

of all five infant behaviours as being effective in bringing about

proximity of mother and child resulting in their mutual attachment,

he agrees that smiling plays a role in the growing mother-infant

relationship. The infant's cry may have different causes and be

seen as a way of communicating with the adult. Wasz-Höckert et al

(86, 88) were able to identify in a spectrografic study four types

of infant cry during the neonatal period: the birth cry, the hunger

cry, the pain cry and the pleasure cry. These different types of

cry may be specific signals to the mother and be able to release

her response.

In lactating primi parous mothers the hunger cry caused an increase

in temperature over the breasts (53). Experience seemed to influence

the degree of this reaction, the more mothers had listened to their
 - 23 -

own infant's cry the higher the skin temperature (89). Some m others

were found to react weakly and others strongly to their infant's cry.

Blauvelt and MacKenna (9) studied infants' special capacity for

response to the environment provided by their mothers. Tactile stimu­

lation of the infant's face from the ears to the lips resulted in

the turning of the infant's face towards the mother. This head-turning

and orienting to the mother's face might be a releaser of maternal

response behaviour. Turkewitz et al (85) noted that normal infants

were more responsive to stimulation of the right than of the left

side of the perioral region. The capacity of a neonate to fix, follow

and alert to a visual stimulus has appeared to be good evidence of

an intact central nervous system (14).Fantz (21, 22) demonstrated the

presence of discrimination ability in neonates and selection of diffe­

rent patterns when vision was tested. Miranda (56) showed that when

newborn infants were presented with two identical pictures, the in­

fants more often looked at the one on the right than the one on the

left. In about 80 per cent of cases mothers have been reported to hold

their infant to the left side of the body (73, 74, 75, 90). The infant

preference for turning to the right and looking to the right may be

a species-specific adaptation to maternal holding to the left - i.e.

when l ooking and turning to the right the baby can see his mother.

The infant's preference for right side looking and turning could also

be a signal to the mother to favour holding to the left.

 - 24 -

At five days of age clinically normal babies spent significantly

more time turning towards their own m other's breast pad than towards

a clean breast pad. This difference was not found at two days. It

may be that after birth the infant gradually develops an appreciation

for its mother, which becomes more specific the more the infant is

exposed to her (55). The symptoms of distress during feeding by diffe­

rent caretaker observed by Burns et al (16) may p artly be explained

by MacFarlane's(55) observations.

Infants of 14 months of age with sleep problems had already been more

irritable during the neonatal period and fussy at a neurological exami­

nation and during a sucking test, than infants without sleep problems

(5 , 6). This illustrates the individuality of the newborn infant and

shows how c areful we have to be with the assumption that parents hand­

ling of infant is always the source of developing problems.

2.2.8 Infant soothability

Korner and Thoman (44) found that some newborn infants could be

soothed more easily than others. Vestibular-proprioceptive stimulation,

as a part of mother-infant body contact, had a highly potent soothing

effect. Soothing can be a very important stimulation of the infant.

Korner et al (41, 42) found that a crying infant during the first weeks

of life when picked up and put to the shoulder, usually stopped crying

and became bright-eyed, thus being able to scan his visual surroundings

and provide himself with a great deal of visual stimulation. Crying

infants may therefore need to be picked up more than infants capable

 - 25 -

of providing visual experiences for themselves. Maternal neglect

of a crying infant may therefore provide the infant with less visual

stimulation and influence psychomotor and even affective development

(43). Birns et al (7) also reported individuality in soothing, a

neonate who is easily soothed by one stimulus (i.e. rocking) tends

to be easily soothed by others (i.e. dummy) and vice versa. Ini another

study (8) the same author reports that individual differences in re­

sponsiveness to stimulation and stability were found over time. Bell

(2) reported on the social interaction between the neonate and his

caregiver. The infant's cry can bring the caregiver into the vicinity

and thus start an interaction, although large individual differences

have been found and the tolerance of caregivers probably shows a great

range. During the first year of life a number of types of behaviour

by mothers in response to crying, such as picking-up, talking/feeding,

touching have been reported by Bell and Ainsworth (3), illustrating

that the individual ways of response found during the neonatal period

also continue later on. The early maternal responses to infant signals

may therefore influence later social interaction.

2.2.9 Early stimulation of infant

In recent years increased attention has been given to the effects

of early stimulation on the human infant. Wachs and Cucinotta (87)

provided thirteen normal newborn infants with 140 minutes of supple­

mentary handling, audio-visual stimulation and rocking, daily for

the first three days after birth. At four days of age these stimulated
 - 26 -

infants showed b etter conditioned head-turning and at thirty days

their visual attenti veness was greater than in control infants.

By 10 months, however, no difference in development was found

between the two groups. The authors suggest that permanence of

effects may not have been achieved in their study because the

optimal amount of critical stimulation may n ot have been reached.

Another explanation might be that the extra stimulation was not

done by the infants' own mo thers or not given at the appropriate

time. If a special sensitive period for the developing mother-

infant relationship exists (35, 38), stimulation by the infant's

own mo ther might be found to produce more lasting advantages.

Ourth and Brown (61) found significantly less crying in infants

to whom f ive hours of extra handling by their own m others was

given daily during the first 4 1/2 days of life, as compared with

control infants without this extra handling (mild, firm support

and rhythmical body stimulation at feeding time).

Distress during feeding in infants with multiple caretakers has been

pointed out by Burns (16). Enrichment of the infant's hospital en­

vironment by means of single caretaker practices could reduce this

distress. In another study (93) infants given extra handling during

the first five weeks of life showed significantly more visual interest

in their environments than non-handled controls. No differences were

found in weight gain, development or general health. In infants of low

birth weight early stimulation might be of extra importance,especially

 - 27 -

if they are born to mothers of low socio-economic level or other

disadvantages. In an experimental group L.B.W.-infants were given

visual, tactile and kinaesthetic stimulation during six weeks in

the neonatal ward (76). Also weekly home visits were made to improve

maternal care during the first year of life. Tests at four wee|ks

and one year indicated greater developmental progress in these infants,

than in controls without extra stimulation and without weekly home

visits.

2.2.10 Conclusion

In the foregoing many different aspects of the importance of the neo­

natal period have been discussed. The observations presented should

have implications for neonatal care as well as for child rearing. In­

fants differ greatly from each other right from the very start. Their

mothers and fathers have different backgrounds and capacities. Flexi­

bility to the individual requirements of each and every family is there­

fore needed. It is regretable that the trend in our society is in

exactly the opposite direction (43): certain child care practices and

certain forms of early stimulation and soothing are considered univer­

sally beneficial regardless of a given child's particular needs. We

should also be vary cautious about labelling some interactive patterns

as "good" or "bad", (31) evidence for this is still lacking and what

might be "good" for one infant-parent couple could be "bad" for another

one.
 - 28 -

3. AIM OF THE PRESENT INVESTIGATION

The purpose of this investigation has been to study how changes

in the care on the delivery floor, maternity ward and neonatal

unit could influence:

1. Maternal and infant behaviour during the neonatal period and

three months later and possible implications for the future.

2. Parents' perception of their relationship to sick infants.

3. Duration of breast feeding.

 - 29 -

4. METHODS

4.1 Direct observations.

Direct observation is a highly suitable method of studying mother-

infant relations (57, 64). The m ost obvious advantage of observation

is that one can see what is happening without having to rely on

poorly established techniques. Therefore direct observation was

preferred to filming and videotape recording (II, III, IV, V),

techniques which may be experienced as a less natural way of obser­

vation. The camera lens moreover covers a restricted area (19) and

analysis becomes excessively time consuming and expensive. A one­

way screen was not available.

During direct observation, on the other hand, one has to be selective

about what is to be observed and recorded. There is always the risk

that valuable information will be missed. In study II and III a

limited number of behavioural items were chosen. Clear-out defini­

tions of these behavioural items were made in advance and agreement

on their occurrence settled.

In study II mothers had not been aware of what was being recorded in

their behaviour. This is especially necessary when o nly a few items

are registered. The presence of an observer may be disconcerting (51)

but mothers during their stay in the maternity ward are used to

contact with the hospital staff, e.g. lectures on infant care, and

did not show any signs of discomfort during the observation. For the
 - 30 -

newborn infant and his mother the maternity ward is a "natural"

environment in our culture, since home deliveries are no longer

practised. Observations (III) of 6 to 16 year olds took place at

school, of younger children at the Child Health Centre, with which

they had had a great number of contacts, making this place familiar

to them. We have thus tried in our studies to carry out observations

in a setting familiar to mothers and children (57).

During our observation in the maternity ward (IV) a great number of

observational items were used. Some o f these items were chosen from

the literature (11, 36, 51, 58, 64, 81) and others from our own

experience. They were defined in co-operation with Marshall Klaus.

A high inter-observer reliability was obtained (IV, V) thus reducing

the bias of each observer. In the follow-up study at three months

(V) the same methods were used as in the maternity ward. By that

time the home has become the infants' natural environment and may

therefore be considered the most suitable setting for studies of

mother-infant relations (57).

4.2 Interviews and questionnaires.

Indirect procedures for studying mother-infant relationship, such

as interviews and questionnaires, have limitations (56, 57). Mothers

may have a limited memory of things that have happened in the past

and retrospective reports have therefore been limited. Mothers may

 - 31 -

moreover give a distorted report of their relationship with their

children, being influenced by what they believe is culturally

expected mother-infant behaviour. In study II no significant

differences were found when different groups of mothers were

asked about child-rearing practices. This could be due to the

limited number of mother-infant pairs investigated, but could

also be an illustration of the limitations of a retrospective

interview, which almost certainly minimizes the "true" diffe­

rences which exist (95). The value of interviews and questionnaires

is, however, greater if they are combined with other methods of

study.

4.3 Scrutiny of hospital records, records from Antenatal Clinics

and Child Health Centres.

As m others often have difficulty in recalling data exactly from

the recent and more distant past (95), both on herself and her

child, other ways of collecting data have been used (I, II, IV,

V). To obtain more reliable data on breast feeding (I) the

children's health records were collected and used in calculating

the duration of breast feeding. In another study (II) the number

of contacts with and number of home visits by the nurses from

the Child Health Centres were directly taken from the health

records. Data concerning the mother's pregnancy, delivery and

earlier obstetrical history were collected from her records from

 - 32 -

antenatal clinics and from the maternity ward (II, IV, V, VI).

To evaluate the post-natal adaptation and health state during

the neonatal period objective criteria like birth weight, labo­

ratory investigations and duration of hospital stay were taken

from the infant's records at the maternity and neonatal wards

(II, III,IV,V,VI). By using objective data from existing records,

made by third persons not aware of our interest in particular

facts, circumstances or measurements, we feel that some of the

disadvantages of interviews and questionnaires have possibly

been compensated for.

 - 33 -

5. RESULTS

5.1 Influences of neonatal care on breast feeding (I + V).

A number of changes in the care of mother and newborn baby have

been made in our maternity ward from 1972 to 1975 in order to

promote breast feeding. The mean duration of breast feeding during

this period has steadily gone up (Fig. 1).

200
VI

150 .

100 . m
IV
i n
50 .

Feb-June May Sept Jan-April

1972 1973 1974 1975

Fig. 1. The mean duration of breast feeding in groups of mothers

with different post partum care.
I = Routine care
II = No w eighing of infant before and after breast feeding
and no supplementary feeding (N=203)
III = As 2, one year later (N=68)
IV = Additional and prolonged information (father not
present at information (N=23)
V = Additional and prolonged information (father present
at information) (N=20)
VI = Naked skin to skin and suckling contact immediately
after delivery (N=21).

We first cancelled routine weighing before and after breast feeding

and supplementary feeding. This was also studied one year later when

the staff were fully used to these new r outines. Thereafter the impact
 - 34 -

of additional and prolonged information and support was studied.

During this part of our studies the giving of information to the

fathers seemed to influence the duration of breast feeding. Finally

when mo thers and infants were given a naked skin to skin and

suckling contact during the first hour after delivery the mean

time of breast feeding increased still further.

Fig. 1 appears very significant, but in evaluating the results one

should remember that during the study period a general trend towards

longer breast feeding was observed in Sweden. According to unofficial

statistics this swing-back came later (17). One has to be careful in

interpreting these results as influences in this field are multi­

factorial and it is difficult to make experimentation sufficiently

simple to justify firm conclusions. An interested and devoted staff

may for example exert unspecific stimulating influences. The possible

effect of cancelling weighing before and after breast feeding came

after a rather long period of time. The decrease of the number of

early failures however came immediately after the change in routines

and can hardly be explained by a general swing-back.

5.2 Holding and carrying newborn infants (II + III + IV).

Almost 80 per cent of ail mothers hold their newborn infants to the

left of the body midline (II), mothers separated from their sick

newborn infants for 24 hours or more doing so considerably less often.

In a follow-up study three years after delivery non-separated, right-

holding mothers had more need for contact with the Child Health Centre
 - 35 -

than did left-holding mothers. Holding to the right, both in non-

separated and separated mothers, was associated with less body

contact between mother and infant than holding to the left. Body

contact during the neonatal period may be of special importance

in the development of mother-infant relationship (37).

These observations may indicate that statistically significant

group differences in mother-infant interaction exist between

left-holding and right-holding mothers. The holding behaviour

may therefore be of a more general biological interest.

Mothers carried their infants from one place to another on the

left arm, on the right or "in the hands". Neonatal care influenced

maternal carrying in primiparae. Thus 15-20 minutes of immediate

post partum "extra contact" eliminated carrying in the hands and

increased the proportion of mothers carrying to the left (Fig. 2).

Separation on the other hand was associated with a slight increase

in carrying in the hands and a decrease in carrying to the left.

The development of the left-side preference when h olding and

carrying a doll, symbolizing a newborn infant, was studied in

305 children from 2 to 16 years. It was demonstrated that this

reference develops gradually during childhood, and that girls

hold and carry more to the left than boys do, both in the total

sample and in each age group studied.

 - 36 -

Left In hands Right

i 1 »
0 50 tOO
Per cent

Fig. 2. Carrying an infant during the first week after delivery

in three groups of primiparae.

A = Separated mothers (N=22)

B = Non-separated mothers (N=125)
C= "Extra contact" mothers (N=21)
Carrying to the left (shaded areas), carrying "in the
hands" (blank areas) and carrying to the right (dotted
areas).

5.3 Extra contact during the first hour post partum (IV + V).

The immediate post partum period may be of particular importance in

the development of the relationship between mother and infant (1, 6,

11, 35, 36, 47, 66, 87). In animal studies (20, 25, 26, 27, 49, 50,

70, 71) it has been demonstrated that early social contact is vital
 - 37 -

to the development of the offspring. In a prospective study we

have therefore examined the effect of "extra contact" during the

first hour following delivery.

Twenty-two healthy primi parous mothers, with normal pregnancies

and deliveries, were given an extra skin to skin and suckling

contact with their infants after delivery ("extra contact"). (A

control group of 20 primi parous mothers and infants was given

routine care, and so was a second control group of 20 multi parous

mothers and infants. At 36 hours maternal and infant behaviour

was observed during breast feeding. At this tage primiparae with

extra contact showed b ehaviour much more like the behaviour oif

multiparae with routine care. Infants of primiparae with routine

care cried most frequently (IV).

At three months a follow-up study of the two groups of primiparae

and their infants was made by means of observation of mother-infant

free play and a personal interview with the mothers. Background

data concerning pregnancy, delivery, neonatal period and the first

three months at home w ere comparable in the two groups.

Mothers in the "extra contact"group spent more time kissing and

looking en face at their infants, and the infants smiled more often

and cried less frequently (V), boys and their mothers seemed to be
more influenced by the "extra contact" than girls and their mòthers.

These two studies are descriptive. Problems of methodology are many

and are not finally solved. The interpretation of the differences in

 - 38 -

behaviour is hazardous and must be made with great caution. It is,

however, notable how results of different studies in both humans

and animals tend to fit into a similar pattern (20, 27, 34, 35, 37,

38, 40, 65, 68). Among mothers and infants a large number may have

individual needs. For example mothers with an unwanted pregnancy

might not be capable of accepting and benefiting from the early

"extra contact" with their infants. And in fact we have experienced

that during the period following our studies some mothers have

refused the "extra contact" offered to them. One has therefore

to be very cautions in offering all mothers this contact imme­

diately after delivery. The offer should be made in an open-minded

way, permitting the mother to make her own c hoice.

5.4 Parents' perception of contact with their sick newborn

infants (VI).

The parents' perception of contact with their sick newborn infants

was investigated by means of a questionnaire five days after birth.

A c lassification was devised to determine the severity of the infant's

medical condition. Such factors as gestational age, mode of delivery,

diagnosis, number of days in the neonatal ward and complications and

treatment were included in this classification.

Mothers of the infants who w ere most severely ill felt that the

infant was theirs later and felt they were less important to the

infant than mothers with healthier infants. Mothers delivered by

 - 39 -

Caesarean section reported that it took at least one day before

they could touch their infant, whereas mothers delivered vaginally

could in almost all cases touch their infant immediately or some

hours after delivery.

Fathers felt that they were less important to their infants during

the hospital stay than mothers. From this preliminary study no firm

conclusions can be drawn but questions can be formulated more

clearly for future investigation. The design of a future study

should be focussed upon separating the effect of each of the three

factors (severity of infant's illness, mode of delivery and time

to first maternal touch of infant after delivery) on the contact

between parents and their sick newborn infants during the neonatal

period.
 - 40 -

6. INTERPRETATIONS

The relatively short period of "extra contact" during the first

hour following delivery (IV, V) can hardly in itself explain the

differences in maternal and infant behaviour later on. Mothers

and infants during this early contact might however have had an

opportunity to exchange signals, which may be of importance for

the establishment of mother-infant synchrony. Consequently the

development of mother-infant relationship may proceed more

smoothly. Other variables such as parity of the mother, family,

social background, parents' age and health may be of equally

great importance. The same holds true for the mother's relation­

ship with her husband, her own p arents, the planning and course

of pregnancy, mode of delivery and so on. From a biological point

of view taking care of a newborn infant is a delicate task. The

optimal physical condition of the newborn child is characterised

by rather narrow boundaries. This is so with regard to, for example,

temperature regulation, calory requirements, need for oxygen,

regulation of water and salt metabolism and so on. These boundaries

have not been known to parents and in fact science has only recently

revealed their importance. The newborn infant needs protection

against too great departures from these needs. During this sensitive

phase of development this need is probably best served by a pattern

of maternal behaviour which is for the most part genetically deter­

mined.
 - 41 -

The importance of the first hour after delivery should not be over­

emphasised. Mothers and infants have a great range of individual

patterns of behaviour and interaction. The ability to care for the

child can be learned, since differences between primiparae and

multiparae in this respect are well known. In study IV primiparae

with "extra contact" showed a behaviour during breast feeding much

like the behaviour of the more trained and more experienced multi­

parae with routine care after delivery. This "extra contact" might

have put the primiparae in a favourable position, which, in a way,

could be compared to the position of the multiparae with more train­

ing and experience.

The "extra contact" might have had other physiological advantages

as well. Through a close skin to skin contact the infant is perhaps

kept warm so his unstable temperature regulation immediately after

delivery is protected and not disturbed by our routines, like bathing,

weighing and so forth. We usually cover the baby's back with a blanket,

a heat-panel is not used. No instances of low body temperature have

been reported in the "extra contact" groups. The regulation of body

temperature may have had an economical start through this extra con­

tact.

A very unusual observation was made at one year. Three out of 21

mothers with extra contact during the first hour following delivery

were still partly breast feeding their infants as opposed to none

 - 42 -

of the 19 control mothers. This extraordinarily long time of breast

feeding is highly unusual in our country and whether desirable or

not, perhaps the most remarkable result of our studies.

 - 43 -

ACKNOWLEDGEMENTS

I wish to express my sincere gratitude to my "doulas" Professor

Jan Winberg, who introduced me to this intriguing and fascinating

field and encouraged me in his very personal and enthusiastic way

throughout the study. I am al so most grateful to Professor Michael

Bohman for his interest, helpful advice and generosity in placing

the resources of his department at my disposal. I would like to

thank Professor Karl-Henrik Gustavson for providing me with the

facilities which made the completion of this study possible.

Two parts of this study are the results of colloboration with

Professor Marshall Klaus, who was my host for six weeks in Cleve­

land, and I am de eply indepted to him for stimulating discussions,

correspondence and support. My many co-authors, especially Britt

Wiberg, are thanked for their enthusiasm, many ideas and kind co­

operation.

Mrs Yvonne Andersson has been very thorough in her technical assi­

stance and most helpful during different parts of this work.

Skilled typing of the manuscripts was done by Mrs Birgitta Gärling

and Mrs Mayvor Burwall.

Statistical analyses were performed by Lennart Nilsson and Anders

Nylén. Bernard Vowles' help in preparing the English manuscripts

 - 44 -

has been very much a ppreciated.

I am al so obliged to the staff of the Departments of Paediatrics,

Gynaecology and Obstetrics and the personnel of the Child Health

Centres in Umeå for their kind co-operation.

Finally my sincere thanks to all other friends and colleagues for

their support and generous help.

 - 45 -

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