Effect of the baby-friendly initiative on infant abandonment in a Russian hospital.

OBJECTIVE: To study whether early mother-infant contact with suckling and rooming-in reduces the rate of infant abandonment. DESIGN: The infant abandonment rate was studied at a Russian hospital before and after the introduction of early mother-infant contact with suckling and rooming-in. SETTING: Maternity Hospital 11 , a public hospital in St Petersburg, Russia, was chosen as the site of this study because it recently changed its maternity care practices, implementing portions of the United Nations Children's Fund Baby-Friendly Hospital Initiative. INTERVENTIONS: In mid 1992, Maternity Hospital 11 changed its practices in accord with the Baby-Friendly Hospital Initiative, encouraging early contact, suckling, and rooming-in of the mother and infant from birth to the time of discharge from the hospital. PATIENTS: The location of a mother's maternity hospital is related to her residential district. Maternity Hospital 11 serves an urban working-class community, with most mothers receiving prenatal care. All deliveries at this hospital from 1987 to 1998 were studied. MAIN OUTCOME MEASURE: Infant abandonment. RESULTS: The rate of infant abandonment at Maternity Hospital 11 was studied from 1987 to 1998, 6 years before and 6 years after the implemented changes in mother-infant contact. The mean (+/-SD) infant abandonment rate decreased from 50.3 +/- 5.8 per 10,000 births in the first 6 years to 27.8 +/- 8.7 per 10,000 births in the next 6 years following implementation of the Baby-Friendly Hospital Initiative. CONCLUSION: Encouraging early mother-infant contact with suckling and rooming-in may provide a simple, low-cost method for reducing infant abandonment.

The obstetrical and postpartum benefits of continuous support during childbirth.

The purpose of this article is to review the evidence regarding the effectiveness of continuous support provided by a trained laywoman (doula) during childbirth on obstetrical and postpartum outcomes. Twelve individual randomized trials have compared obstetrical and postpartum outcomes between doula-supported women and women who did not receive doula support during childbirth. Three meta-analyses, which used different approaches, have been performed on the results of the clinical trials. Emotional and physical support significantly shortens labor and decreases the need for cesarean deliveries, forceps and vacuum extraction, oxytocin augmentation, and analgesia. Doula-supported mothers also rate childbirth as less difficult and painful than do women not supported by a doula. Labor support by fathers does not appear to produce similar obstetrical benefits. Eight of the 12 trials report early or late psychosocial benefits of doula support. Early benefits include reductions in state anxiety scores, positive feelings about the birth experience, and increased rates of breastfeeding initiation. Later postpartum benefits include decreased symptoms of depression, improved self-esteem, exclusive breastfeeding, and increased sensitivity of the mother to her child's needs. The results of these 12 trials strongly suggest that doula support is an essential component of childbirth. A thorough reorganization of current birth practices is in order to ensure that every woman has access to continuous emotional and physical support during labor.

The doula: an essential ingredient of childbirth rediscovered.

Eleven randomized control trials examined whether additional support by a trained lay person (called a doula), student midwife or midwife, who provides continuous support consisting of praise, encouragement, reassurance, comfort measures, physical contact and explanations about progress during labor, will affect obstetrical and neonatal outcomes. The women were healthy primigravidas at term. Meta-analysis of these studies showed a reduction in the duration of labor, the use of medications for pain relief, operative vaginal delivery, and in many studies a reduction in caesarian deliveries. At 6 weeks after delivery in one study a greater proportion of doula-supported women were breastfeeding, reported greater self-esteem, less depression, a higher regard for their babies and their ability to care for them compared to the control mothers. Observations during labor showed that fathers remained farther away from mothers than doulas, talked and touched less. When the doula was present with the couple during labor the father offered more personal support. The father-to-be' s presence during labor and delivery is important to the mother and father, but it is the presence of the doula that results in significant benefits in outcome.

The perinatal paradigm: is it time for a change?

Two different care procedures are presented to raise the difficult question of whether we should completely reevaluate our paradigms of care in the perinatal period. In this thorough review, should we continue to use the same framework of beliefs in deciding on the benefits and risks of any care procedure?

The frequency of suckling. A neglected but essential ingredient of breast-feeding.

This article presents data to suggest that an essential ingredient for the success of breast-feeding is feeding frequency. Increasing the frequency of feeding decreases nipple pain and breast tenderness, significantly increases milk output and infant weight gain, decreases the peak serum bilirubin levels, increases the success of lactation, and decreases ovulation, markedly improving the contraceptive effect of breast-feeding.

Effects of social support during parturition on maternal and infant morbidity.

Because continuous social support during labour is a component of care in many societies but inconsistent in our own, the clinical effect of support during labour on maternal and neonatal morbidity were studied. Social support was provided by female companions. Four hundred and sixty five healthy primigravidous women were enrolled using a randomised design. Compared with 249 women undergoing labour alone 168 women who had supportive female companions throughout labour had significantly fewer perinatal complications (p less than 0.001), including caesarean sections (7% v 17%, p less than 0.01) and oxytocin augmentation (2% v 13%, p less than 0.001), and fewer infants admitted to neonatal intensive care (p less than 0.10). Of the women who had an uncomplicated labour and delivery requiring no interventions, those with a companion had a significantly shorter duration of labour (7.7 hours v 15.5 hours, p less than 0.001). This study suggests that constant human support may be of great benefit to women during labour.

Frequency of breast-feeding and serum bilirubin concentration.

Recent studies suggest that the three- to four-hour feeding regimens followed in many maternity units for breast-feeding mothers may not be physiological and that human infants should be fed more frequently. To determine the effects of frequency and length of brest-feeding in the first days after birth, we studied 55 mothers and their infants. Infants who nursed on average more than eight times per 24 hours in the first three days of life had significantly lower serum bilirubin levels (65. v 9.3 mg/fL, P less than .01) than those who fed less than eight times per 24 hours. The results of this investigation suggest that present breast-feeding policies that reduce or limit the number of feedings may interfere with the normal processes that eliminate bilirubin from the newborn infant.

Effect of lung volume on expiratory time in the newborn infant.

The effect of an increased end-expiratory lung volume on inspiratory and expiratory duration was examined in 13 term infants at 4, 30, and 70 h of age. This was accomplished by the administration of a continuous positive airway pressure (CPAP) of 0, 3, and 6 cmH2O by use of a face mask connected to a pneumotachometer, and by measurement of the timing of the respiratory cycle over 1-min intervals. At increasing functional residual capacity (FRC) there was a progressive increase in expiratory time (TE) and fall in respiratory rate, with a variable effect on inspiratory time (TI). As CPAP increased from 0 to 6 cmH2O, the TI/TE ratio fell from 0.75 to 0.62 (P less than 0.01), 0.90 to 0.66 (P less than 0.001), and 0.87 to 0.64 (P less than 0.001) at 4, 30, and 70 h, respectively. We conclude that alterations in end-expiratory lung volume significantly alter expiratory duration in the newborn infant at term. This may be analogous to the vagally mediated tonic control of expiratory time with changing FRC recently described in anesthetized animals.

Neonatal pattern vision: a predictor of future mental performance?

The visual fixation responses of 33 high-risk neonates to patterned stimuli were rated as normal, suspect, or abnormal in an attempt to predict future intellectual performance. For comparison purposes, a neurologic examination was aslo administered. Follow-up studies based on autopsies and neurologic and psychological testing agreed with the neonatal visual preference ratings in 27 cases, but with the neurologic examination ratings in only 22 cases. This preliminary study suggests that neonatal visual testing is a promising technique for evaluating brain integrity in the newborn period.

The effect of a low continuous positive airway pressure on the reflex control of respiration in the preterm infant.

The airway occlusion technique was used to measure the strength of the Hering-Breuer inflation reflex before and during the administration of low pressure CPAP. In five of 12 preterm infants studied in the first two weeks of life, CPAP did not alter the inflation reflex. In the other seven premature infants, shortened rather than lengthened inspiratory efforts were observed on occlusion 32 times of CPAP but only twice on CPAP. In seven term infants at 1 to 2.5 hours of age this shortening was noted only twice in 58 occlusions. In the preterm infants exhibiting short responses, the peak inspiratory pressure generated in response to occlusion rose on CPAP from 3.4 to 7.1 cm H2O (p less than 0.005), while respiratory rate fell from 61 to 49 breaths/minute (p less than 0.025). This data suggests that CPAP enhances these infants' ability to adjust to increased respiratory loads, possibly by the elimination of a Hering-Breuer deflation reflex.

Bradycardia in preterm infants: indications and hazards of atropine therapy.

Eight preterm infants are presented to demonstrate the indications and hazards of using atropine for treatment of bradycardia in the high-risk premature nursery. Three infants developed bradycardia following initiation of nipple feedings, one following gavage feedings, three following surgical manipulation of visceral structures, and one associated with presence of chronic pulmonary disease. It is suggested that the first seven cases represent "reflexic bradycardia," probably vagally mediated and thus amenable to atropine therapy, whereas the eighth is an example of "hypoxic bradycardia" where administration of atropine may be detrimental. Polygraphic monitoring, arterial blood gases, and the clinical status are helpful in distinguishing reflexic from hypoxic bradycardia. These parameters should be evaluated prior to institution of atropine therapy.