Adik Levin. MD. PhD
BIRTH 21:1 March, 1994
ABSTRACT: A mother-infant neonatal unit was established in 1979 at Tallinn Children’s Hospital in Estonia to provide medical and nursing care to newborn and premature babies and their mothers. Its leading principles are 24-hour care by the mother, minimal use of technology, and little contact between the baby and medical and nursing staff. The unit was based on a conceptual model of the “psychological and biological umbilicus,” which proposes that this connection binds the mother and infant together during the early weeks of life. Separation of mother and baby disrupts this important tie and may have adverse consequences for both. This paper presents data comparing weight gain during the first 30 days of life for a group of 159 preterm and full-term infants who were admitted to the unit between 1988 and 1989. Eighty-seven infants were cared for by their mothers, and 72 by nurses because their mothers were unwilling or unable to stay with the infants in the hospital. The holistic, humanistic approach used in the unit represents a truly baby-friendly hospital. (BIRTH 21:1, March 1994)
Adik Levin is Head of the Newborn and Premature Children’s Department at Children’s Hospital, Tallinn, Estonia.
Address correspondence to Marshall H. Klaus, MD, Children’s Hospital, 747 Fifty-second Street, Oakland, CA 94609.
© 1994 Blackwell Scientific Publications, Inc.
After the birth of a child, the physical umbilical cord between the infant and mother is severed, but the two remain connected by what we have conceptualized as a “psychological and biological umbilicus”. To ensure the optimum development of the infant and mother, it is necessary to maintain the integrity of the biological umbilical cord through at least the first month of life. This tie includes many elements, such as normal vaginal delivery without the use of drugs, breastfeeding immediately after birth so that the infant can benefit from colostrum, continuous physical contact between mother and newborn, and minimal infant contact with other caregivers or technological equipment. Infants are born relatively sterile and free of infectious organisms, and during the first month of life the biological umbilical cord serves as a natural incubator, providing the infant with protection against potentially pathogenic environmental organisms. Aggressive, high-technology medical therapy often creates increased problems for the infant because it breaks this natural biological umbilicus. Gottfried, for example, noted that researchers and clinicians have suggested that “contemporary management of newborns in NICUs (neonatal intensive care units) may be responsible for iatrogenic complications and may not be conducive to optimal development” (1).
The psychological umbilical cord represents the social and emotional bond between the mother and baby. It begins to form during pregnancy and becomes increasingly important during the early months of life, and must remain intact throughout the child’s developing years. The mother-baby unit that was established at Tallinn Children’s Hospital in Estonia is based on principles designed to maintain the integrity of the biological and psychological umbilical cord.
Maternal care has many advantages for the infant, including better weight gain, fewer infections, decreased need for aggressive medical care (antibiotics, intravenous infusions), and improved social and psychological development. Maternal care also has many advantages for the mother, including more rapid physical recovery from childbirth, development of confidence in her ability to mother the child, and development of strong attachment to the infant.
In most modern neonatal units, the care of pre-term or sick full-term infants is characterized by several principles. Mothers arc not hospitalized with their sick babies, but arc discharged from maternity hospitals directly to their homes. During their stay in maternity units they are generally allowed to be with their babies at daytime feedings, but at night are usually in their own rooms, separate from their infants. (This is especially true in Eastern European countries.) After the mothers are discharged they can spend the day with their infants, but they leave the hospital for the night. In a few progressive units, a week before the infant is discharged, mothers are permitted to live in with their babies in a private room to develop confidence in their ability to care for the infants at home and improve their adaptation to the infants. Mothers and other family members can come to see the child whenever appropriate in most neonatal units in Western countries.
The common factors in most of these units is that the infant is in contact with a frequently changing medical and nursing staff, is often exposed to high-technology medical care, and has limited or no contact with the parents. It is our hypothesis that these factors increase the risk of infectious diseases and thereby the risk of neonatal morbidity, and decrease the opportunity for development of positive parent-infant attachment relationships.
Establishment of the Mother-Infant Unit
In 1979 a special department for the care of preterm (<37 weeks gestational age at birth) and sick full-term infants was established in Tallinn, Estonia. The unit contains 35 beds for preterm infants and 35 beds for sick full-term infants, because of a great shortage of nursing staff at this time, mothers were enlisted to care for their infants. Except for technical medical and nursing care, mothers are taught and expected to provide all of the infant's care and to stay in the hospital with the infant until discharge. Nurses administer drugs and injections, supervise the infant's feeding program, and assist with infant examinations (radiographs, ultrasonography, collection of blood and urine specimens). They also prepare mothers for caregiving, and act as consultants by helping the mothers with breastfeeding and caring for their babies. Generally only 4 nurses are on duty to supervise the care of the 70 infants and mothers. The Ieading principles of this unit are 24 hour care by the mother, with assistance from nurses and hospital staff as necessary; promoting breastfeeding whenever possible; minimal use of technology; and little contact between baby and medical and nursing staff who might expose the infant to pathological microbes. These principles help to maintain the biological and psychological ties between mother and infant. After the unit was established, we noticed considerable decreases in the number of infectious diseases in the infants, and in the duration of intravenous infusions and antibiotic therapy. We also noticed an apparent improvement in the infants' neurological development. Thus, for the first time in Estonia, a neonatology department had been set up where the integrity of the biological and psychological umbilical cord could be maintained. Parent and Infant Populations Admissions to the mother-infant unit come from all maternity hospitals in Tallinn, north Estonia, and west Estonia. Every year about 700 mothers are admitted, the majority (95%) coming with their infants directly from local maternity hospitals. Mothers who have had cesarean sections or perinatal complications are given short-term care at the maternity hospital and join their infants as soon as possible. In rare cases a mother cannot join her infant because of problems such as a severe illness or deciding that she does not want the infant. [ fig3.gif ] The department is a component of a multispecialty children's hospital, which also has a respirator department for all infants who require assisted ventilation. Maternity hospitals send sick newborns, preterm infants, and their mothers to the unit usually on the third to seventh day of life, and the respirator department sends infants one to two days after ventilation has been discontinued. The number of children treated in the unit between 1988 and 1992 is shown in Figure 3. A total of 53 to 65 percent of the infants were full term, but had various health problems, such as congenital malformations, perinatal asphyxia, infections, or meconium aspiration syndrome. All full-term infants born in Tallinn or in north or west Estonia who required medical treatment were treated in the unit, because no other hospitals in the region can care for them. Of the full-term infants admitted to the unit, 35 percent were born to mothers under 21 years of age, 75 percent were from unplanned pregnancies, and 88 percent were born to mothers who had some type of physical health problem (pyelonephritis, anemia, cardiovascular disease). Because of the many social and economic changes that have occurred in Estonia since its independence in 1989, the birth rate is decreasing. Abortion is used by many women as a method of family planning. This decreasing birth rate may explain the decreased numbers of infants admitted to the unit in 1991 and 1992. Most preterm infants admitted to the unit weighed more than 1500 g at birth. They remain in the unit until they weigh at least 2000 g, are able to feed well, are gaining weight, and are physically stable. Infants are not discharged until their mothers are comfortable caring for them. Maternity and Newborn Practices Mothers are invited to begin to care for their infants as soon as they arrive in the unit. To help them feel more relaxed, fathers and other family members can visit several times a week. Two mothers and two infants are in each room. Mothers eat their meals in their rooms, and can visit together in a common lounge area. Many bring photographs, flowers, and other items from home to make the rooms more personal. Every infant has her or his individual caregiving equipment. Children are with their mothers continuously, and mothers are often in physical contact with their babies using the kangaroo method of skin-to-skin contact (2-4). Mothers are taught to massage their infants, which they do every day. They are expected to keep notes of their infant's state of health, and medical and nursing staff give aid or advice as needed. Psychologists and nurses provide classes for mothers and fathers on infant care, breastfeeding, and relaxation. Almost all mothers breastfeed their infants on demand. When a preterm infant is too young to breastfeed, mothers express breast milk and administer it by means of nasogastric tube. Nurses change the nasogastric tubes each day, but the mothers administer the feedings, usually while allowing their infant to suckle at the breast. Infants whose mothers are unable to breastfeed, or whose mothers do not stay in the unit, are fed with formula, although the supply of infant formula in Estonia is very limited. In addition to the nursing staff, the unit employs six neonatologists, two psychologists, and other support staff such as massage therapists and therapists to provide treatment with water baths and electrophoresis for the infants. Gynecologists and other medical consultants are available to provide necessary care for the mothers. Supplemental oxygen and intravenous therapy are provided to infants who require them, but the use of invasive medical procedures (radiographs, venipunctures) is minimized. When the neonatologist determines that an infant has a functional neuromuscular problem, such as feeding difficulties or hypertonia, the infant also receives an electrophoresis treatment daily for 7 to 10 days. This involves placing two electrodes, one positive and the other negative, at specific locations on the infant's body, and administering a very small current through them. Infant Weight Gain [ table1.gif ] Since a general index of a child's physical status in the first month of life is weight gain, to examine the effects of maternal care on this outcome measure, we compared weight gains during the first month of life of two groups of infants who received care in the mother-infant unit between 1988 and 1989. The first group of 87 infants were cared for by their mothers, and the second group of 72 by nurses because their mothers were unable or unwilling to care for them in the unit. Only infants who weighed more than 2000 g at birth were studied, because their mothers were generally able to assume caregiving responsibilities immediately after birth. Of the infants in the maternal care group, 39 were pre-term and 48 were full term. Of the infants in the nurse care group, 30 were preterm and 42 were full term (Table 1). Infants in both groups were similar with respect to birthweight, although by age 6 days the mean weight of those in the maternal care group was about 100 g higher than that of infants in the nurse care group. Because all infants weighed more than 2000 g, this difference was not considered clinically significant. Tables 2 and 3 show the differences in weight gain among infants in the two groups during the first 20 days of life, from 20 to 30 days, and over the entire first month. Data are presented separately for preterm and full-term infants, and for first- and second-born children in the two groups. [ table2.gif ] The findings indicate that the preterm infants in the maternal care group gained considerably more weight than preterm infants in the nurse care group (p < 0.0001). In full-term infants the difference was less but still statistically significant. Thus it appears that maternal care is an important factor in promoting infant weight gain during the neonatal period, and is more significant the more immature the newborn is. [ table3.gif ] Discussion At the 1990 World Summit for Children, a Baby Friendly Hospital Initiative was launched by representatives from the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), 71 heads of state, and other experts. The focus of this initiative is to remove obstacles to breastfeeding that women frequently encounter in hospitals. To qualify for designation as baby friendly, hospitals must implement 10 practices that promote successful breastfeeding, such as give the newborn no food or drink other than breast milk, practice rooming-in, and encourage breastfeeding on demand (5-8). Although promotion of breastfeeding is an important goal, we believe that it is only one of many components of a truly baby-friendly environment. In addition, hospitals have to promote the integrity of the biological and psychological ties between the mother and infant. The mother-infant unit at Tallinn Children's Hospital illustrates one organizational strategy that can be used to provide a baby-friendly environment for newborn infants and mothers. The caregiving approach is more comprehensive than that generally advocated in the current baby-friendly UNICEF campaign, because it helps to maintain the integrity of the biological and psychological ties between the mother and infant, and thus promotes infant health and the development of maternal-infant attachment. The biological ties are preserved by maintaining, continuous contact between mother and infant, minimizing the contact between the infant and nursing and medical personnel, and restricting the use of invasive medical procedures for the infant. The psychological ties are strengthened by providing the mother with support from an interdisciplinary team that includes physicians, nurses, psychologists, massage therapists, and other staff. Mothers can rest and recover their physical and emotional strength in the unit before they take their infants home, and receive instruction and support in breastfeeding and infant care. The entire family is encouraged to support the mother and newborn infant. The approach used in this unit is very different from that used in most modern neonatal intensive care units (9, 10). Although parents may be allowed to visit their infants in these units, the primary responsibility for infant care rests with the nursing and medical staff. As a result, parents often feel insecure and incompetent in curing for their infant after hospital discharge (11, 12). In addition, most modern neonatal intensive care units use a wide variety of medical interventions, which may actually increase the risk of iatrogenic neonatal complications, and further compromise the integrity of the infant's immune system. This mother-infant unit includes many strategies advocated for promoting parent-infant bonding, such as transporting the mother to be with her newborn, promoting rooming-in, and allowing the mother to have an opportunity for "nesting," or creating a special environment for the infant (13). Although we do not promote early discharge, mothers receive many of its benefits by being able to live in the unit with their infants. This approach may also minimize some of the stresses experienced after early discharge by providing mothers with an opportunity to develop confidence in their mothering abilities before taking their infants home. This unit represents a beginning effort to refocus traditional medical care of preterm and sick newborn infants and to provide a humanistic and baby-friendly environment. Further research is necessary to examine the effects of this type of care for infants and their families. We encourage health caregivers in other countries to explore ways to change the organization of neonatal units so that children's hospitals are baby friendly in all ways. Acknowledgments The author acknowledges the assistance of Marshall Klaus, MD, Director of Academic Affairs at Children's Hospital, Oakland, California, and Lynda Harrison, RN, PhD, Professor of Nursing, and Assistant Academic Vice President, University of Alabama, Tuscaloosa, Alabama, in translating and editing this manuscript. References Gottfried AW. Environment of newborn infants in special care units. In: Gottfried AW, Gaiter JL, eds. Infant Stress Under Intensive Care: Environmental Neonatology. 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