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Commentary: A Lesson from Eastern Europe

Harrison, RN, PhD, and Marshall H. Klaus, MD

BIRTH 21:1 March 1994; 45-6

    Lynda Harrison is Professor of Nursing and Assistant Academic Vice President at The University of Alabama, Tuscaloosa, Alabama, and Marshall Klaus is Professor in the Department of Pediatrics, University of California. San Francisco. California.
 
This report by Adik Levin begins to balance the How of information from west to east, and describes an innovative unit that was in part stimulated by an acute shortage of nurses. The paradigm Dr. Levin selected is based on a somewhat different belief system than that used in the United Stales. As a consequence, he chose another set of scientific data that he considered important for the development of the unit.
 
Other similar units developed dormitories adjacent to the nursery for mothers to live in and care for their infants, including Kahn et al at Baragwanath in South Africa (1), Tefari and Ross in Ethiopia (2), and Largia and Martinez at Sarda Hospital in Buenos Aires, Argentina (3). J. Torres (personal communication, 1978) in Santiago, Chile, and Donald Garrow (4) in High Wycombe, England, developed similar rooming-in units for mothers of sick and growing preterm infants. As Levin observed, they also noted significantly improved breastfeeding, an early acceptance and ability of the mothers to care for their infants, improved communication and information sharing between parents and hospital staff, and markedly reduced hospital costs. Although they did not fully document differences in the health of the infant in the hospital, their success in remarkably improving lactation increased the infant's chance of surviving during the first year of life in what was often a hostile environment.
 
We had the unique opportunity to observe the Mother-Infant Unit at Tallinn Children's Hospital in action. Although it operates with minimal funds in spartan facilities, it appears to offer many advantages when the infant is out of trouble and growing. These include strengthening the attachment of the mother to her infant, allowing her to be a major caretaker and thereby improving both her caretaking abilities and her self-esteem. The unit also increases her chances to learn by sharing ideas with other resident mothers and hospital staff, and increases the success of lactation.
 
We found it interesting that fathers were allowed to visit this unit only three times a week. Dr. Levin is attempting to seek funding to allow expansion of the unit so that fathers could stay with the mothers at night, and go to work during the day. Efforts to increase involvement of fathers would provide an important source of support for the mothers. Klaus and Kennell described a unit in the Leningrad Obstetrical Institute, where mothers stayed in the hospital until their preterm infants were discharged (4). Unlike the mothers in the Tallinn unit, those in Leningrad were not allowed to participate in their infants' care except to breastfeed, and fathers were not allowed to visit at all. They reported that the Leningrad mothers "appeared very depressed" (4, p 176). Although the mothers in Tallinn did not appear depressed, we wondered whether they would benefit from more interaction and support from their families.
 
In this paper Levin reports for the first time improved growth rates and decreased rates of infection for infants who were cared for by their mothers. Although he suggests that the reduced infection rate is the result of isolating the mother-infant dyad, the data are not yet available to support this hypothesis. Further research is needed to identify the mechanism responsible for the increased weight gain among infants in the maternal care group.
 
The recently discovered beneficial effects of breastfeeding preterm infants, including the significant decrease in necrotizing enterocolitis (5) and improved intelligence quotient at age eight years (6), suggest that a reevaluation of our present high-technology arrangements for the growing preterm infant is in order.
 
As we attempt to improve health care and lower costs in the United States, we also need to conduct a thorough examination of models such as the Estonian "Baby Friendly" unit, and to develop caregiving practices that maintain the "psychological and biological umbilicus."
 
References
  1. Kahn E, Wayburne S, Fouche M. Baragwanath premature unit: An analysis of the case records of 1000 consecutive admissions. S Afr Med J 1954; 28: 453-456
  2. Tafari N, Ross SM. On the need for organized perinatal care. Ethiop Med J 1973; 11: 93-100
  3. Kennell JH, Klaus MH. The perinatal paradigm: Is it time for a change? Clin Perinatal 1988: 15 (4): 801-813
  4. Klaus MH, Kennell JH. Parent-infant bonding, 2nd ed. St. Louis: CV Mosby, 1982; 176-177
  5. Lucas A, Cole TJ. Breast milk and neonatal necrotizing enterocolitis. Lancet 1990; 336: 1519-1523
  6. Lucas A, Morley R, Cole TJ, Lister G, Leeson-Payne C. Breast milk and subsequent intelligence quotient in children born preterm. Lancet 1992; 339: 261-264
 
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