Edmund P. Joyce C.S.C. Chair in Anthropology
Director, Mother-Baby Behavioral Sleep Laboratory
University of Notre Dame
Author of Sleeping with Your Baby: A Parent’s Guide to Cosleeping

Where a baby sleeps is not as simple as current medical discourse and recommendations against cosleeping in some western societies want it to be. And there is good reason why. I write here to explain why the pediatric recommendations on forms of cosleeping such as bedsharing will and should remain mixed. I will also address why the majority of new parents practice intermittent bedsharing despite governmental and medical warnings against it.

Definitions are important here. The term cosleeping refers to any situation in which a committed adult caregiver, usually the mother, sleeps within close enough proximity to her infant so that each, the mother and infant, can respond to each other’s sensory signals and cues. Room sharing is a form of cosleeping, always considered safe and always considered protective. But it is not the room itself that it is protective. It is what goes on between the mother (or father) and the infant that is. Medical authorities seem to forget this fact. This form of cosleeping is not controversial and is recommended by all.

Unfortunately, the terms cosleeping, bedsharing and a well-known dangerous form of cosleeping, couch or sofa cosleeping, are mostly used interchangeably by medical authorities, even though these terms need to be kept separate. It is absolutely wrong to say, for example, that “cosleeping is dangerous” when roomsharing is a form of cosleeping and this form of cosleeping (as at least three epidemiological studies show) reduce an infant’s chances of dying by one half.

Bedsharing is another form of cosleeping which can be made either safe or unsafe, but it is not intrinsically one nor the other. Couch or sofa cosleeping is, however, intrinsically dangerous as babies can and do all too easily get pushed against the back of the couch by the adult, or flipped face down in the pillows, to suffocate.

Often news stories talk about “another baby dying while cosleeping” but they fail to distinguish between what type of cosleeping was involved and, worse, what specific dangerous factor might have actually been responsible for the baby dying. A specific example is whether the infant was sleeping prone next to their parent, which is an independent risk factor for death regardless of where the infant was sleeping. Such reports inappropriately suggest that all types of cosleeping are the same, dangerous, and all the practices around cosleeping carry the same high risks, and that no cosleeping environment can be made safe.

Nothing can be further from the truth. This is akin to suggesting that because some parents drive drunk with their infants in their cars, unstrapped into car seats, and because some of these babies die in car accidents that nobody can drive with babies in their cars because obviously car transportation for infants is fatal. You see the point.

One of the most important reasons why bedsharing occurs, and the reason why simple declarations against it will not eradicate it, is because sleeping next to one’s baby is biologically appropriate, unlike placing infants prone to sleep or putting an infant in a room to sleep by itself. This is particularly so when bedsharing is associated with breast feeding.

When done safely, mother-infant cosleeping saves infants lives and contributes to infant and maternal health and well being. Merely having an infant sleeping in a room with a committed adult caregiver (cosleeping) reduces the chances of an infant dying from SIDS or from an accident by one half!

Research

In Japan where co-sleeping and breastfeeding (in the absence of maternal smoking) is the cultural norm, rates of the sudden infant death syndrome are the lowest in the world. For breastfeeding mothers, bedsharing makes breastfeeding much easier to manage and practically doubles the amount of breastfeeding sessions while permitting both mothers and infants to spend more time asleep. The increased exposure to mother’s antibodies which comes with more frequent nighttime breastfeeding can potentially, per any given infant, reduce infant illness. And because co-sleeping in the form of bedsharing makes breastfeeding easier for mothers, it encourages them to breastfeed for a greater number of months, according to Dr. Helen Ball’s studies at the University of Durham, therein potentially reducing the mothers chances of breast cancer. Indeed, the benefits of cosleeping helps explain why simply telling parents never to sleep with baby is like suggesting that nobody should eat fats and sugars since excessive fats and sugars lead to obesity and/or death from heart disease, diabetes or cancer. Obviously, there’s a whole lot more to the story.

As regards bedsharing, an expanded version of its function and effects on the infant’s biology helps us to understand not only why the bedsharing debate refuses to go away, but why the overwhelming majority of parents in the United States (over 50% according to the most recent national survey) now sleep in bed for part or all of the night with their babies.

That the highest rates of bedsharing worldwide occur alongside the lowest rates of infant mortality, including Sudden Infant Death Syndrome (SIDS) rates, is a point worth returning to. It is an important beginning point for understanding the complexities involved in explaining why outcomes related to bedsharing (recall, one of many types of cosleeping) vary between being protective for some populations and dangerous for others. It suggests that whether or not babies should bedshare and what the outcome will be may depend on who is involved, under what condition it occurs, how it is practiced, and the quality of the relationship brought to the bed to share. This is not the answer some medical authorities are looking for, but it certainly resonates with parents, and it is substantiated by scores of studies.

Understanding Recommendations

Recently, the American Academy of Pediatrics (AAP) SIDS Sub-Committee for whom I served (ad hoc) as an expert panel member recommended that babies should sleep close to their mothers in the same room but not in the same bed. While I celebrated this historic roomsharing recommendation, I disagreed with and worry about the ramifications of the unqualified recommendation against any and all bedsharing. Further, I worry about the message being given unfairly (if not immorally) to mothers; that is, no matter who you are, or what you do, your sleeping body is no more than an inert potential lethal weapon against which neither you nor your infant has any control. If this were true, none of us humans would be here today to have this discussion because the only reason why we survived is because our ancestral mothers slept alongside us and breastfed us through the night!

I am not alone in thinking this way. The Academy of Breast Feeding Medicine, the USA Breast Feeding Committee, the Breast Feeding section of the American Academy of Pediatrics, La Leche League International, UNICEF and WHO are all prestigious organizations who support bedsharing and which use the best and latest scientific information on what makes mothers and babies safe and healthy. Clearly, there is no scientific consensus.

What we do agree on, however, is what specific “factors” increase the chances of SIDS in a bedsharing environment, and what kinds of circumstances increase the chances of suffocation either from someone in the bed or from the bed furniture itself. For example, adults should not bedshare if inebriated or if desensitized by drugs, or overly exhausted, and other toddlers or children should never be in a bed with an infant. Moreover, since having smoked during a pregnancy diminishes the capacities of infants to arouse to protect their breathing, smoking mothers should have their infants sleep alongside them on a different surface but not in the same bed.

My own physiological studies suggest that breastfeeding mother-infant pairs exhibit increased sensitivities and responses to each other while sleeping, and those sensitivities offers the infant protection from overlay. However, if bottle feeding, infants should lie alongside the mother in a crib or bassinet, but not in the same bed. Prone or stomach sleeping especially on soft mattresses is always dangerous for infants and so is covering their heads with blankets, or laying them near or on top of pillows. Light blanketing is always best as is attention to any spaces or gaps in bed furniture which needs to be fixed as babies can slip into these spaces and quickly to become wedged and asphyxiate. My recommendation is, if routinely bedsharing, to strip the bed apart from its frame, pulling the mattress and box springs to the center of the room, therein avoiding dangerous spaces or gaps into which babies can slip to be injured or die.

But, again, disagreement remains over how best to use this information. Certain medical groups, including some members of the American Academy of Pediatrics (though not necessarily the majority), argue that bedsharing should be eliminated altogether. Others, myself included, prefer to support the practice when it can be done safely amongst breastfeeding mothers. Some professionals believe that it can never be made safe but there is no evidence that this is true.

More importantly, parents just don’t believe it! Making sure that parents are in a position to make informed choices therein reflecting their own infant’s needs, family goals, and nurturing and infant care preferences seems to me to be fundamental.

Our Biological Imperatives

My support of bedsharing when practiced safely stems from my research knowledge of how and why it occurs, what it means to mothers, and how it functions biologically. Like human taste buds which reward us for eating what’s overwhelmingly critical for survival i.e. fats and sugars, a consideration of human infant and parental biology and psychology reveal the existence of powerful physiological and social factors that promote maternal motivations to cosleep and explain parental needs to touch and sleep close to baby.

The low calorie composition of human breast milk (exquisitely adjusted for the human infants’ undeveloped gut) requires frequent nighttime feeds, and, hence, helps explain how and why a cultural shift toward increased cosleeping behavior is underway. Approximately 73% of US mothers leave the hospital breast feeding and even amongst mothers who never intended to bedshare soon discover how much easier breast feeding is and how much more satisfied they feel with baby sleeping alongside often in their bed.

But it’s not just breastfeeding that promotes bedsharing. Infants usually have something to say about it too! And for some reason they remain unimpressed with declarations as to how dangerous sleeping next to mother can be. Instead, irrepressible (ancient) neurologically-based infant responses to maternal smells, movements and touch altogether reduce infant crying while positively regulating infant breathing, body temperature, absorption of calories, stress hormone levels, immune status, and oxygenation. In short, and as mentioned above, cosleeping (whether on the same surface or not) facilitates positive clinical changes including more infant sleep and seems to make, well, babies happy. In other words, unless practiced dangerously, sleeping next to mother is good for infants. The reason why it occurs is because… it is supposedto.

Recall that despite dramatic cultural and technological changes in the industrialized west, human infants are still born the most neurologically immature primate of all, with only 25% of their brain volume. This represents a uniquely human characteristic that could only develop biologically (indeed, is only possible) alongside mother’s continuous contact and proximity—as mothers body proves still to be the only environment to which the infant is truly adapted, for which even modern western technology has yet to produce a substitute.

Even here in whatever-city-USA, nothing a baby can or cannot do makes sense except in light of the mother’s body, a biological reality apparently dismissed by those that argue against any and all bedsharing and what they call cosleeping, but which likely explains why most crib-using parents at some point feel the need to bring their babies to bed with them —findings that our mother-baby sleep laboratory here at Notre Dame has helped document scientifically. Given a choice, it seems human babies strongly prefer their mother’s body to solitary contact with inert cotton-lined mattresses. In turn, mothers seem to notice and succumb to their infant’s preferences.

There is no doubt that bedsharing should be avoided in particular circumstances and can be practiced dangerously. While each single bedsharing death is tragic, such deaths are no more indictments about any and all bedsharing than are the three hundred thousand plus deaths or more of babies in cribs an indictment that crib sleeping is deadly and should be eliminated. Just as unsafe cribs and unsafe ways to use cribs can be eliminated so, too, can parents be educated to minimize bedsharing risks.

Moving Beyond Judgments to Understanding

We still do not know what causes SIDS. But fortunately the primary factors that increase risk are now widely known i.e. placing an infant prone (face down) for sleep, using soft mattresses, maternal smoking, overwrapping babies or blocking air movement around their faces. In combination with bedsharing, where more vital normal defensive infant responses and may be more important to an infant (like the ability to arouse to bat a blanket which momentarily falls to cover the infants face when its parent moves or turns) these risks become exaggerated especially amongst unhealthy infants. When infants die in these obviously unsafe conditions, it is here where social biases and the sheer levels of ignorance associated with actually explaining the death become apparent. A death itself in a bedsharing environment does not automatically suggest, as many legal and medical authorities assert, that it was the bedsharing, or worse, suffocation that killed the infant. Infants in bedsharirng environments, like babies in cribs, can still die of SIDS.

It is a shame and certainly inappropriate that, for example, the head pathologists of the state of Indiana recommends that other pathologists assume SIDS as a likely cause of death when babies die in cribs but to assume asphyxiation if a baby dies in an adult bed or has a history of “cosleeping”. By assuming before any facts are known from the pathologist’s death scene and toxicological report that any bedsharing baby was a victim of an accidental suffocation rather than from some congenital or natural cause, including SIDS unrelated to bedsharing, medical authorities not only commit a form of scientific fraud but they victimize the doomed infant’s parents for a third time. The first occurs when their baby dies, the second occurs when health professionals interviewed for news stories (which commonly occurs) imply that when a baby dies in a bed with an adult it must be due to suffocation (or a SIDS induced by bedsharing). The third time the parents are victimized is when still without any evidence medical or police authorities suggest that their baby’s death was “preventable,” that their baby would still be alive if only the parents had not bedshared. This conclusion is based not on the facts of the tragedy but on unfair and fallacious stereotypes about bedsharing.

Indeed, no legitimate SIDS researcher nor forensic pathologist should render a judgment that a baby was suffocated without an extensive toxiological report and death scene investigation including information from the mother concerning what her thoughts are on what might or could have happened.

Whether involving cribs or adult beds, risky sleep practices leading to infant deaths are more likely to occur when parents lack access to safety information, or if they are judged to be irresponsible should they choose to follow their own and their infants’ biological predilections to bedshare, or if public health messages are held back on brochures and replaced by simplistic and inappropriate warnings saying “just never do it.” Such recommendations misrepresent the true function and biological significance of the behaviors, and the critical extent to which dangerous practices can be modified, and they dismiss the valid reasons why people engage in the behavior in the first place.

For More Information:
A Popular Parenting Book
Sleeping with Your Baby: A Parent’s Guide to Cosleepingby James J.McKenna (2007). Platypus Press.

The Arm’s Reach Co-Sleeper- a bassinet/crib which Dr. McKenna has recommended as one way to enjoy close proximity with a baby for parents who are concerned about bed-sharing

The Scientific Perspective
McKenna, J., Ball H., Gettler L., Mother-infant Cosleeping, Breastfeeding and SIDS: What Biological Anthropologists Have Learned About Normal Infant Sleep and Pediatric Sleep Medicine. Yearbook of Physical Anthropology 50:133-161 (2007)

McKenna, J., McDade, T., Why Babies Should Never Sleep Alone: A Review of the Co-Sleeping Controversy in Relation to SIDS, Bedsharing and Breastfeeding (pdf). Paediatric Respiratory Reviews 6:134-152 (2005)

Physicians blogging about breastfeeding
Online milk sales, beyond “buyer beware”

with one comment

A new study in Pediatrics has spawned provocative headlines, contrasting images of human milk as “a nourishing elixir, or a bacterial brew.” Researchers anonymously bought breast milk from 102 online sellers. Milk orders were often packaged poorly, arrived well above freezing, and — as one might expect with milk unrefrigerated for days — were rife with bacteria.

But that’s really not the whole story. First, consider who participated in the study. By design, the authors communicated with sellers only by email, and cut off the conversation if the sellers asked about the recipient infant or wanted to talk by phone or in person. Milk was shipped to a rented mailbox to make the process anonymous. Of the 495 sellers the authors contacted, 191 sellers never responded, 41 stopped corresponding before making a sale, and 57 were excluded because they wanted to communicate by phone or asked about the recipient baby. Another 105 did not complete a transaction, leaving 102 of the original 495 sellers approached who actually shipped milk. Of these, half the samples took more than 2 days to ship, and 19% had no cooling agent in the package.

It’s highly plausible that milk sent with no questions asked, via 2 day or longer shipment, and (in 1 and 5 cases) without any cooling whatsoever, was collected with less attention to basic hygienic precautions. The bacterial load in study milk samples therefore doesn’t tell us about the relative safety of milk obtained following a conversation between buyer and seller about the recipient baby and then shipped overnight on dry ice in a laboratory-quality cooler. Indeed, when the authors compared online milk purchases with samples donated to a milk bank after a screening and selection process, they found much lower rates of bacterial contamination. The authors acknowledge this limitation in the study, but that subtlety has been lost in the media coverage.

It’s also not clear from the study to what extent bacteria found in milk reflect contamination vs. “good bacteria” that are present in milk. A growing literature demonstrates that “fresh from the tap” breast milk contains a wide variety of bacteria, and these bacteria colonize the infant’s gut. The study reported in Pediatrics did not distinguish between species of bacteria, nor did they compare the frozen samples with freshly expressed breast milk. The salient question is not, “Is there any bacteria in milk bought online?” but “How much more disease-causing bacteria is present in milk bought online, compared to milk that’s fresh from the breast?”

Moreover, news coverage has not considered the broader context of infection risk in infant feeding. Powdered infant formula is not sterile. Therefore, both the World Health Organization the Centers for Disease Control and Prevention recommend feeding all newborn babies liquid formula. If a newborn is fed powdered formula, the WHO and the CDC recommend cleaning bottles in a dish washer with hot water and a heated drying cycle, heating water to at least 158 degrees F (70 degrees Celsius) to make formula, and using formula within 2 hours of preparation.

Studies suggest that most parents don’t follow these guidelines. Importantly, formula packaging doesn’t include the CDC language, instead advising parents to “ask your baby’s doctor about the need to sterilize water and preparation utensils before mixing formula.”

Online information from formula companies is even less explicit. In an article titled, “10 Things to Know about Bottle Feeding,” a formula company web site suggests:

If baby wakes you up to eat, try this tip from New York City mom Michele Bender: ‘I’d measure the formula and keep the powder, water, and bottle on my night table. I could mix it right there rather than having to go to the kitchen. It sounds minor, but at 3 a.m., one less step is great.’

These instructions directly contradict WHO and CDC recommendations by suggesting parents use room temperature water to mix formula. Given the very large number of infants who are fed powdered formula, inaccurate information on formula preparation is a far greater hazard for infant health than milk bought online.

What we need is education on safe handling of food for infants to minimize the risk of food-borne infection for babies. ABM has published evidence-based guidelines for human milk collection and storage, and HMBANA has developed detailed guidelines on safe milk collection. Broadly disseminating this information will provide mothers who are milk sharing with guidance on how to minimize risk. Health care providers need to engage families, inquire about milk sharing, and discuss this practice in an informed consent context, rather than dismissing milk sharing as unacceptable. Similarly, we need formula-feeding families to have complete information on how to minimize risk of catastrophic infections.

And then there’s the “ick” factor – what The Verge alluded to in their coverage as “Women and their dirty femine fluids.”

In a provocative essay titled, Milk sharing and formula feeding: Infant feeding risks in comparative perspective?, Karleen D. Gribble and Bernice L. Hausman explore why health authorities proscribe human milk sharing as dangerous, but provide parents with information to assist them in the management of the risks of formula feeding.

There is a well recorded historical legacy of suspicion concerning mothers and their milk. In its current iteration, this suspicion leads to the conclusion that corporations are considered more trustworthy than women to provide healthful nutriment to infants.

Cultural proscriptions around breastfeeding and milk-sharing are not new, but rather reflect centuries of debate about the role of women’s bodies in society. As Lia Moran and Jacob Gilad write in From Folklore to Scientific Evidence: Breast-Feeding and Wet-Nursing in Islam and the Case of Non-Puerperal Lactation:

It should be clear by now that in many societies the rules regarding breast-feeding, were laid down by men, and tend to support male-dominated institutions. For example, in those countries which observe Muslim civil law, the duty of a woman to feed her husband’s children, the duration of feeding and the conditions under which she may feed children other than her own, thus establishing links of milk-kinship, are all prescribed by a male-dominated paternal legal system. The feeding of one woman’s child by another has been used in different societies to make peace between two tribes, to consolidate clan unity, to prevent marriage, to create clients, and in sum, to attain objectives which lie far beyond the nursing woman’s own interest.

Indeed, the nursing woman’s own interest is not part of the discourse around online milk sales. The market for human milk exists because of the mismatch between promoting “breast is best” and prioritizing real support for mothers and babies. Moms buy milk online because they want to breastfeed, but they are unable to meet their infant’s needs with their own milk. Often, these moms are victims of the “Booby Traps” that stymie so many women, ranging from uninformed health care providers to outdated maternity practices and bottom-of-the-barrel policies for parental leave in the United States. In other cases, a mother’s body simply can’t make enough milk for her baby, despite heroic efforts to sustain breastfeeding. We could obviate much of the demand for online milk sales if we changed policies and practices. We might also find ways for more moms to make enough milk if we devoted a fraction of the resources currently directed at erectile dysfunction to lactation dysfunction.

“Breast milk as bacterial brew” pushes lots of cultural buttons — from the “ick factor” to our reliance on mass-produced and marketed substitutes, rather than women, to nourish our children. Let’s stop pressing buttons, and start looking for solutions, so that more families can achieve their infant feeding goals.

Alison Stuebe, MD, MSc, is a maternal-fetal medicine physician, breastfeeding researcher, and assistant professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine. She is a member of the board of the Academy of Breastfeeding Medicine. Posts on the ABM blog reflect the opinions of individual authors, not the organization a whole.

"Pack your hospital bag early! I wish I'd planned for an early arrival. My twins arrived at 28 weeks, and I wasn’t prepared at all. My husband didn’t have a clue about what to bring me, or where to find things in the house. Being in hospital for a long time, and not having my home comforts, was quite stressful." 
Claire

"Learn about c-sections and pain medications, even if you hope to avoid them. I skipped the chapters on caesareans in my pregnancy books but, like many women, ended up having one. And if you change your mind about pain relief during labour, it's good to know your options." 
Gill 

"Due dates aren't exact, so don't stress if your baby is a little late." 
Becky 

"Avoid the childbirth horror stories people want to share. I took every story to heart and was terrified. I could have saved myself a lot of worry. My imagination was much worse than the actual event." 
Kate 

"We have this preconceived notion that all labours start a certain way and progress at a certain rate. The truth is, births are as different as each child. Going into labour with an open mind makes for a more positive experience." 
Helen 

"I tore and had to have an episiotomy during my first birth. So during this pregnancy, I talked with my midwife about how to avoid them both. I wound up having neither, and I was amazed by how great I felt afterwards!" 
Carol 

"Learn natural pain-relief techniques, even if you plan on taking drugs. Drugs don't always numb you completely. If your labour goes really fast, you may not have the chance to get pain medication until you're well into the process." 
Ayesha 

"Take lots of fruit and high-fibre snacks. You'll need them to get your digestive system moving again, and hospital food isn’t always very nutritious!" 
Mariam 

"Bring a nursing pillow. The hospital pillows don't provide enough height and support to get the baby into a comfortable feeding position, and your arms may be tired after labour." 
Bethany 

"Take your own nightie for breastfeeding, or pyjamas. The ones they gave me were awful." 
Emma 

"Bring breast pads. I started leaking breastmilk on my last day in the hospital." 
Trish 

"It can get annoying asking nurses for things like lanolin cream for sore nipples and extra pairs of comfortable knickers that will keep your pads on. So make sure you pack these things in your hospital bag." 
Tara 

"If you've bought disposable knickers for after the birth, try them on before you pack them in your bag. I didn't and found out they were too small for me, by which time it was too late!" 
Mel

See what to pack in your hospital bag and our preparing for birth videos.

Take a look at what mums wish they had known during the birth and after the birth.

http://www.babycentre.co.uk/a1024812/what-i-wish-id-known-about-childbirth-before-the-birth#ixzz2iqmzIFt5

Washington, DC -- The nation’s ob-gyns have redefined ‘term pregnancy’ to improve newborn outcomes and expand efforts to prevent nonmedically indicated deliveries before 39 weeks of gestation. In a joint Committee Opinion, The American College of Obstetricians and Gynecologists (The College) and the Society for Maternal-Fetal Medicine (SMFM) are discouraging use of the general label ‘term pregnancy’ and replacing it with a series of more specific labels: ‘early term,’ ‘full term,’ ‘late term,’ and ‘postterm.’  
 
The following represent the four new definitions of ‘term’ deliveries:

• Early Term:  Between 37 weeks 0 days and 38 weeks 6 days
• Full Term:    Between 39 weeks 0 days and 40 weeks 6 days
• Late Term:   Between 41 weeks 0 days and 41 weeks 6 days
• Postterm:     Between 42 weeks 0 days and beyond

“This terminology change makes it clear to both patients and doctors that newborn outcomes are not uniform even after 37 weeks,” said Jeffrey L. Ecker, MD, chair of The College’s Committee on Obstetric Practice. “Each week of gestation up to 39 weeks is important for a fetus to fully develop before delivery and have a healthy start.”

On average, a pregnancy with a single fetus lasts 40 weeks from the first day of the last menstrual period. This calculation determines a pregnant woman’s estimated date of delivery (EDD). Previously, babies were considered ‘term’ if they were born anytime between three weeks before and two weeks after the EDD (37–42 weeks of gestation). “Until recently, doctors believed that babies delivered in this five-week window had essentially the same good health outcomes,” said Dr. Ecker.

Research over the past several years, however, shows that every week of gestation matters for the health of newborns. The last few weeks of pregnancy within these 40 weeks allow a baby’s brain and lungs to fully mature. Babies born between 39 weeks 0 days and 40 weeks 6 days gestation have the best health outcomes, compared with babies born before or after this period. This distinct time period is now referred to as “Full Term.”

Planned deliveries before 39 weeks 0 days should occur only when there are significant health risks to a woman and/or the fetus in continuing the pregnancy, according to Dr. Ecker. Sometimes delivery before 39 weeks 0 days is unavoidable, such as when a woman’s water breaks or contractions come early. 

The College and SMFM encourage physicians, researchers, and public health officials to adopt these new precisely-defined terms in order to improve data collection and reporting, clinical research, and provide the highest quality pregnancy care.

Committee Opinion #579 “Definition of Term Pregnancy” is published in the November issue of Obstetrics & Gynecology.

See Committee Opinion #561 “Nonmedically Indicated Early-Term Deliveries.”

Go to acog.org/About_ACOG/ACOG_Departments/Deliveries_Before_39_Weeks

For more information on The College’s partnership with the US Department of Health and Human Services “Strong Start” public awareness campaign to reduce unnecessary elective deliveries before 39 weeks’ gestation, visit http://1.usa.gov/1hztQRS

The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of approximately 57,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org

Does professional labour support diminish the father’s role? Many couples find it’s just the opposite

http://www.todaysparent.com/pregnancy/giving-birth/doulas-and-dads/  Apr 5, 2010 Matt J. Simmons

My wife and I never did find a doula. Late in her pregnancy, we moved to a small town in northern BC and were unable to locate one. Instead, I stayed up late every night, reading books on what a doula actually does, desperately trying to retain as much information as possible. On the big day, I did my best to mimic the actions I had read about. While I managed reasonably well, I can’t help but think I was somehow doing the work of three people: dad, partner and doula. I would have been more than happy to share some of that responsibility.

Why a doula?

“I was really scared with my first child,” admits Annie Thompson. “I didn’t know what to expect.” Most first-time mothers share Annie’s fear of the unknown. Births aren’t always straightforward and, leading up to the event, the amount of information you have to take in is quite daunting. In prenatal classes, Annie and her husband, Cam, learned about the role of the doula and made the decision to include one in their birth plans. Connecting with one was easy in their case: Their prenatal instructor doubled as a doula and agreed to take them on.

A doula offers an expectant mother knowledgeable support — she’s seen it all before. It goes back to a more traditional style of birth when the women of a community were more closely connected. However, a doula’s support is just as valuable in a high-tech hospital birth as in a home birth, perhaps even more so. Research shows that births with a doula tend to have shorter labours and fewer interventions, and result in a greater sense of satisfaction for the moms.

What exactly can couples expect a doula to do? Simple: anything they want. If all they need is for someone to pat them on their backs while they get on with the task at hand, a doula can do just that. Alternatively, she can be hands-on, coaching mom every step of the way. Or, and this is probably the most likely choice, she can be somewhere in between. “My one piece of advice to expectant parents,” says Barber, “[is] to be sure that your doula is clear on the role you want her to take.” For Cam and Annie, Barber’s role was on the sidelines, advocating on their behalf and continually reminding them what they were there for. Her vision was to help both partners through the birth experience.

Where does dad fit in?

But what about dads? Do doulas supplant dads in childbirth? In this era, fathers want to be involved, and the idea that doulas are a replacement for them is a common worry.

Tom Lehar initially questioned the value of including a doula in the birth of his first child. “I guess at first I thought it seemed like an invasion of privacy,” he admits. “But very quickly I let that go.” As Annie Thompson points out, in a hospital birth it’s not as if the couple is alone anyway. A doula actually provides a buffer between the couple and the hospital staff, if you so choose, minimizing unwanted intrusions into your intimacy. “I didn’t really care what other people were up to,” continues Lehar. “I was focused only on Kate. I guess that’s the idea behind the whole doula thing. I didn’t need to worry about details; I could just be with Kate.”

A dad’s emotional stake in the birth can quickly cloud his judgment and cause him to forget what he’s learned from books and prenatal classes. “It is an emotionally charged event,” agrees Cam. “No matter how well you prepare, you still don’t know what you’re going to go through. I’ve never felt so out of control as I did when my kids were being born.” It’s natural to react when you see your partner in distress; it’s natural to want to make it stop. What’s hard to remember, in the heat of the moment, is how to help.

Because doulas know what to expect in a labour, they take the pressure off partners — especially first-time dads — who would otherwise constantly wonder, “What’s happening now?” Doulas complement the help dads give their partners, working together with them to create the most comfortable atmosphere possible. Shawna Barber supported Cam and Annie through their first birth. “I have met with a few expectant fathers who were a bit resistant in the beginning, before they understood fully what the role of a doula is,” she acknowledges. But by working with the couple before and during labour, Barber helped Cam feel better equipped to support his wife. “I felt like I had somebody there with experience,” Annie says. “She was there the whole time, reminding Cam how to help me.”

As Doulas of North America (DONA) explains in its report on the relationship between dads and doulas, “a father may not understand a woman’s instinctive behaviour during childbirth and may react anxiously to what a doula knows to be the normal process of birth.” Anxiety breeds tension, and tension is decidedly unhelpful in the delivery room.

Cam had just this experience. “Annie was in the bathroom,” Cam recalls, “and I was thinking, ‘Holy cow, Annie just lost her mind!’ He explains that Annie’s fear of what was happening to her body suddenly took over, and that, in turn, scared Cam. “But Shawna just said to me: ‘This is transition.’ That was a big help.” Barber then suggested that Cam help his wife out of the bathroom and back into bed, which he did. “That one sentence made a big difference overall,” Cam says.

While a doula may initially be a stranger, she can quickly become a friend. Prenatal coaching and planning for the birth can be as important as the birth itself, as can postpartum assistance. Cam says meeting with Barber several times before the birth made him more comfortable with the idea of having her there. “We got to know her,” he says. After the birth, Barber stayed with the new family to help with breastfeeding and, before she left, she made sure that the couple had everything they needed. “We had several visits after Lily was born,” Barber says, “and I am fortunate enough to still have contact with them six years, and several moves, later!”

The pairing of doulas and dads is a winning combination. As Barber says, “Moms feel looked after; dads feel functional and needed. Everyone wins.”

Making it work

For all a doula’s benefits, you are still bringing a stranger into an intimate family event. The following tips will help ensure it’s a great experience:

• Meet with your doula several times before the birth to get comfortable with one another.

• Talk with your partner — and with your doula — about the role you would like her to take. For example, will she be very hands-on with your partner, or would you prefer she coach you to do most of the comforting?

• Remember to ask questions and don’t keep misgivings to yourself. This is an important experience for everyone and the less uncertainty there is, the better.

• If possible, meet with your doula after the birth. The labour and delivery of your child is not the only challenge facing new parents; your doula can help you through those first few months as you adjust to life with a new addition to your family.

Where to find a doula

• dona.org Doulas of North America (DONA) offers information and advice on doulas, as well as a list of contact details for registered doulas in Canada and around the world.

• bcdoulas.org The Doula Service Association is a doula referral service based in BC.

Listen to any group of new parents talking about their birth experience, and here's a phrase you'll almost certainly hear. "At least," someone will say, "the baby was all right. That's all that really matters." That comment will come after one of the group has poured out a story that fell very far short of ideal – a story in which she felt she was ignored, not listened to, disempowered, neglected. A birth that typically started well, but turned into a scary (sometimes terrifying) rollercoaster, from which the new family was left so shaken that they were genuinely grateful that they were even still alive.

But the fact that the mother and baby are still alive isn't the only thing that matters. Certainly not in 2013, when birth is safer than it's ever been: today, the risk that either you or your baby won't make it is minute. So how come we're still setting such a low bar for our ideas of whether childbirth was successful? And what damage is that doing to our children?

These questions are at the heart of a campaign launching today that calls for a rethink on what matters most in childbirth in the western world in the 21st century. Childbirth charity Birthrights is calling for a reappraisal of how we judge a successful birth: no longer should it be merely about physical health, but about psychological health as well. According to new research carried out by Mumsnet for Birthrights, fewer than half of all women in the UK get the birth they want.

The new figures, based on a survey of 1,100 Mumsnet users who have had babies in the past three years, found only 68% of pregnant women were given a choice about where to give birth, 31% did not feel in control of their birth experience; 23% said they weren't given a choice about where they wanted to be during labour, and 18% didn't think health professionals had listened to them. A shocking 24% of women who had had instrumental births said they had not consented to the procedure.

And does it matter? Yes it does. In fact, the body of evidence about how much it matters is mushrooming, so that it seems almost absurd to anyone who knows anything about children's development that we still think that a baby's physical health at the birth is all that matters. The Mumsnet survey gives a clue to why: most of the mothers questioned said their baby's birth affected how they felt about themselves, and 41% felt that impact was negative (rising to 73% in women who had had instrumental deliveries). Almost half the women questioned thought the birth experience had affected their relationship with their baby, and for 22% the impact was negative; again, for women who had an instrumental delivery that proportion rose dramatically, to 59%.

The survey didn't give figures on fathers, but it's clear from other research that the way a birth pans out affects a father's early bonding with his child, as well as his future relationship with his partner. And all of that is vital in providing the newborn with an environment that's as secure as possible, because security is what every child needs in early life.

Ask any child development specialist, and they'll tell you the same thing: the best predictor of a child's future wellbeing, future educational attainment, future mental health and future happiness is the quality of the bond formed between that child and his or her primary caregivers in the hours, days, months and years after birth. When a woman begins her life as a mother feeling low in confidence, unsure about how she feels about her child and unhappy in herself, she won't be as able to give herself to the bonding process as she will if she embarks on motherhood feeling in control, empowered and validated by the experience. Give a new mother confidence, and you give her the best possible start in the hardest job in the world – and that's the best possible start you can give her baby, too. Give her a good birth experience, and the road ahead is at least on a level, and maybe even downhill. Give her a traumatic birth, and you give her a hill to climb – and, of course, she has a baby to carry as well. Birth isn't just about two people still breathing: we're doing the next generation a huge injustice by assuming it is.