Optimum transition for an infant from intra- to extra-uterine life centres on the mode of birth which, ideally, is a gentle and gradual integration from life in fluid—with its lack of gravity and its darkness, muted sounds and little sensory stimuli—to an extra-uterine existence with the mother providing the central social–sensory protective buffer zone/sanctuary. After birth, infants seem to be pre-sensitised, pre-adapted and responsive to extra-uterine life although they remain highly dependent on sustained bodily contact with the mother, that is, touching, being touched, smelling her, moving with her, breastfeeding, looking at her and hearing her voice.

The composition of the mother’s milk along with her breastfeeding function is a direct link to the mother’s entero-immune system and duplicates the role played by the umbilical cord prior to birth, assuring the convergence of an array of sensory skin-to-skin experiences and integrating in-utero prenatal experiences with postnatal ones. The presence or absence of nurturing very early in life influences how the infant’s developing brain interprets the world and its relationships—as either peaceful, pleasurable and loving, or hostile, painful and violent—depending on the trust or anxiety experienced in this first relationship (Schore 2001, 2002).

It has been demonstrated that infants, whether premature or full-term, when resting on their mother’s chest are able to maintain lower blood pressure, efficient energy use and optimum thermoregulation (whether needing to be warmer or cooler), and experience less stress (Ashmore 2001; Moore et al 2007). Research data supports the notion that newly born infants feel most comfortable in an environment approximating that before birth. It has been suggested that this is because newly born infants are more comfortable if they hear the constant rhythmical beat of the mother’s heart, which has been perceived by the fetus from the beginning of the third trimester when functional hearing commences (Birnholz & Benacerraf 1983; Lecanuet & Schaal 1996). Interestingly, mothers have a strong tendency to hold their infants on the left side of their bodies, close to their hearts, regardless of whether they are right- or left-handed (Saling & Cooke 1984).

For prematurely born and mature infants, the beneficial effects of a postnatal milieu that closely resembles the womb experience have already been recognised. Kangaroo mother care, as this form of care has been termed, is characterised by extended periods of skin-to-skin contact between newborn preterm infants and their mothers or fathers (WHO 2003). Kangaroo care came about as a response to the high death rate in preterm babies seen in Bogota, Columbia, in the late 1970s. There, the death rate for premature infants was 70%. The babies were dying of infections, respiratory problems, and simply due to lack of attention. Researchers discovered that babies who were held close to their mothers’ bodies for large portions of the day not only survived, but thrived. In Western nations, hospitals that encourage kangaroo care typically have their mothers or fathers provide skin-to-skin contact with their preterm (or sick) babies for several hours each day. Many midwives recommend that mothers who are finding it difficult to settle their babies use a modified form of kangaroo care.

In kangaroo care, the infant is usually held by the mother in an upright position beneath her clothing, between her breasts, and is clad with only a diaper and a hat. The baby’s head is placed over the mother’s heart. Kangaroo care can be practised as soon as the neonate is medically stable enough to be temporarily taken out of the incubator. It has been used on infants weighing less than 1500 g and may last for anywhere between 1 and virtually 24 hours per day. The child’s self-regulatory access to breastfeeding is encouraged.

Research provides clear evidence that premature infants who have received kangaroo care in addition to regular hospital care are well positioned with respect to many aspects of their development (Feldman et al 2002). For instance, when held skin-to-skin their heart rate and respiration are more stable. In addition, they cry less, experience more deep sleep and show greater weight gain, and are discharged earlier from hospital. Kangaroo care further appears to accelerate neuromaturation; lactation is also more successful and lasts longer. Equally important, parents practising kangaroo care seem to bond more easily with their infants and to be more confident in their ability to care for them. Evidence is also accumulating that full-term neonates derive similar benefits from skin-to-skin contact as preterm infants (Ferber & Makhoul 2004).

A South African study by Ferber and Makhoul (2004) evaluated the effects of kangaroo care on neurobehavioural responses of healthy newborns. Forty-seven pairs of mothers and infants were separated into two groups. One group received standard birth-room care and one group received kangaroo care. The kangaroo care lasted for 1 hour and commenced 15–20 minutes after birth. Results showed that the infants exposed to kangaroo care not only slept longer but also showed more flexor actions and postures and fewer extensor actions than the control group (Ferber & Makhoul 2004). The researchers concluded that kangaroo care may very well influence sleep and motor movements in infants shortly after birth. However, the long-term benefits of kangaroo care are not yet known. Very early findings speculate that about 6 hours after birth may be long enough for the baby to stabilise physiologically, and to initiate the maternal care response. By six weeks of age the baby may be ready to move beyond skin-to-skin contact on the mother’s chest. By then the baby has better head control, breastfeeding is established, and the mother has recovered from the birth.

Appropriate social and emotional support for pregnant women during the antenatal period is an important aspect of preparation for both mother and infant to achieve the best possible circumstances for baby’s future growth. In supporting transition to life outside the womb, infants benefit both before and after birth when mothers are well supported both physically and emotionally during pregnancy and the immediate postnatal period, when skin-to-skin contact is initiated and where there is early exposure to breastfeeding.

Midwives facilitate the optimal management of a healthy mother–infant dyad by:

• limiting the need for invasive procedures and analgesia during pregnancy, labour and birth through focused midwifery labour care

• encouraging participation/support of significant other(s) during labour and birth

• promoting skin-to-skin contact at time of birth

• routinely transitioning the well baby with other family members

• initiating early breastfeeding, within the first hour

• providing appropriate ongoing breastfeeding support

• avoiding or postponing any non-essential routine procedures, such as weighing, vitamin K injection, bathing

• promoting avoidance or postponement of any elective procedures, such as tubal ligation sterilisation, during the immediate postpartum period

• facilitating and supporting maternal capacities and appropriate emotions, responses, instincts and motivations to facilitate parenting.

When midwives facilitate a good birth experience for women in their care, they assist a transitional process through a defining experience that for many women may strongly influence how ready they are to embark on motherhood.

A WOMAN’S STORY

Labouring in the warm soft water, I felt completely in synch with my baby; when he entered my birth canal it was with a fluid, fish-like movement that my body facilitated and mirrored, natural dance partners executing instinctive, synchronistic moves perfectly. All too soon the dance was over and my baby was floating out of my body and into my arms to be held in perfect peace and wonder. No distress or trauma, just a gentle integration from inside to outside, with our outside environment feeling womb-like with only candles to lighten the dark, quiet whispers of familiar voices only, midwife and father, and warm water to relax in. Time now to learn a new dance of nurturing, the moves already flowing between us, reciprocal learning and bonding encouraged by our womb space. An oasis of time and experience soon to be left behind but never to be forgotten. [Birth of Lochie, 6 July 1997]

Biosocial needs of infants

Rapid, recent changes in modes of delivery, postnatal practices, parental expectations and feeding options pose new challenges for the mother–infant dyad. Although breastfeeding contributes to better health outcomes for infant and mother, can help to delay a new pregnancy and facilitates attachment, no more than 35 percent of babies worldwide are currently exclusively breastfed during the first 4 months of life. (WHO 2003)

International health programs advocate the importance of the symbiotic mother–infant dyad, and the World Health Organization has noted the inseparable biological and social unit that mother and baby represent with the health and nutrition of each unable to be separated. To define an infant’s biosocial needs and to determine the optimum ways to meet these, it is necessary to consider what is unique about infants and mothers. It is also critical to understand to what extent cultural practices influence parenting and which, as a consequence, may place barriers between a mother and her infant; or why some infant-care practices resonate more emotionally with parents than do others as they attempt to meet both the short- and long-term needs of their infants.

As already discussed, maternal proximity and contact is important to promote breastfeeding and healthy infant sleep, growth and development in general. There is no part of the infant’s fundamental physiological, psychological or neurobiological functioning and development that is not influenced by a variety of ongoing maternal–infant sensory exchanges involving olfactory, auditory, tactile, kinaesthetic, vestibular and visual signals and cues. The work of McCain and Mustard (2006) and Shonkoff and Phillips (2000) established that the early years, beginning during pregnancy, are the most vital in the brain development of every infant and this is therefore the optimal time for early intervention and prevention of conditions which may have negative effects on short- and long-term health and wellbeing.

While approaches to infant care have changed throughout history, even in the present time there remains considerable variation in the ways different cultures handle the care of their infants. Although socialisation has always moulded children to fit particular societal expectations, the question exists as to whether any of the known child-caring approaches succeeds better than others in providing the young infant with an optimal environment for physical and psychological growth. What is known is that parents are inundated with well-meaning advice from healthcare professionals, friends, parents and the media about the ‘best’ way to parent their baby. They also hear and read about all the things that can go wrong if they ‘don’t do it properly’! An increasing number of parents and child-care exponents have come to view the prevalent Western approach to infant care as not sensitive enough to an infant’s innate needs. Instead, they have turned to a childrearing approach that considers the infant to be the best expert in defining their own needs (Hunt & Symonds 1995).

This approach contends that closely observing infant cues and sensitively responding to their expressed needs is a foundation for favourable human development. This includes interpreting crying as a clear communication of a legitimate need and understanding that the emotional demands of infants are as valid as physiological ones. A further characteristic of this parenting approach is the belief that parents have an innate sensitivity to their infant/child’s cues and an instinctive knowledge of the required responses. On a practical level this results in infants being kept in close physical contact with their mothers for most of the day until they start to become mobile, after which physical closeness gradually lessens. In addition to meeting the infant’s needs, when a mother is empowered and confident in her motherhood, she is more likely to understand that her baby’s wants and needs are the same thing and should be met rather than suppressed; and that if they cannot be met, they are at least acknowledged and understood.

Even so, within any culture, different subgroups may vary greatly in their typical childrearing practices. Respect for and understanding and facilitating of different cultural practices within the healthcare setting is an important step in assisting women from different cultures to make the transition to mothering.

For many parents, the transition from what may be a busy working and self-centred life to one in which they have to devote themselves to a baby 24 hours a day, seven days a week, is one of infinite growth, physically, emotionally and spiritually. Some parents feel like they are stumbling around in the dark, lurching from one challenge to another, in a state of tortured sleep deprivation and confusion with the plethora of conflicting parenting philosophies that are readily available on the internet, in books, and at antenatal and postnatal classes, parenting courses, etc. Some are influenced by family and friends; some research and study this new ‘job’ to the maximum; while others go with the flow and do what their parents before them did. Others just struggle to cope with their lives as a whole, both financially and practically. Many women return to work after a few months and find that stresses associated with being in the workforce compound the determined efforts to be a successful and effective parent.

The phenomena of ‘controlled crying’ and ‘controlled comforting’ are increasingly advocated by some healthcare professionals to help exhausted, overly stressed and sleep-deprived mothers and fathers who find their babies’ wakefulness too difficult to cope with. Controlled crying was created by Dr Truby King, who helped establish the Plunket Society and Child Public Health Services in England, and who wrote the book Feeding and Care of Baby in 1913. King’s theories were as controversial in 1913 as they are today, especially since he also believed that women should not gain a higher education as it would affect their maternal function and have a damaging effect on the human race!

The idea behind controlled crying is to teach babies to ‘self-settle’ or put themselves to sleep, so that they eventually stop waking and/or crying during the night. It involves leaving the baby alone to cry for increasingly longer periods of time before providing comfort. Originally, controlled crying was not recommended for babies younger than 6 months of age, but increasingly it is used for much younger babies; even newborns. Understanding the controlled-crying debate is essential, as parents will often ask midwives their opinions about this method of settling baby, particularly as infant sleeping and crying problems are common and adversely affect maternal mental health (Smart & Hiscock 2007). To address this, a number of Australian and New Zealand centres conduct sleep clinics for mothers and babies. There are a number of resources that midwives can direct parents to use to help them make informed choices. For example, the Australian Association for Infant Mental Health has published a good position statement on controlled crying, available on their website (AAIMH 2004).

From the midwifery perspective, then, asking women if they have any particular requests regarding the management of labour, the birth of their baby, or immediate postbirth processes provides an opportunity to accommodate and act upon these requests wherever possible and provide cultural security within the birthing environment. This assists women to maintain the integrity of their cultural needs, and reinforces the notion that there are many different styles, with none being more valid than others.

The role of the midwife, therefore, is to sensitively assess family goals, capabilities and imperatives and determine the uniqueness of each individual family. In this way a midwife can affirm and inform parents as to how best to respond to and nurture their infants within their own contexts and needs. To appreciate the connection between the biological and social needs of infants requires understanding the effect of bonding and attachment, and how theory and research evidence supports the importance of secure attachment.