6 Discussions due in 36 hours

combs

04CH_Mossler_Development.pdf

Home >Education homework help >6 Discussions due in 36 hours

101

4Birth and Neonatal Development

Heatherwalker/RooM/Getty Images

Learning Objectives

After completing this chapter, you should be able to:

• Describe various birth processes, including the techniques used, the roles of different kinds of professionals, and examples of cultural variations.

• Explain the process of labor, including vaginal deliveries and the usefulness of cesarean sections.

• Understand the meaning of Apgar scores and specify how they are used.

• Differentiate between preterm and low-birth-weight infants, identifying the potential consequences for infants born in less-than-ideal circumstances.

• Understand variability in early infant care, including cultural differences, and the associated effects on infant development.

• Describe how choices in infant nutrition can affect infant development.

• Identify initial infant states of arousal and reflexes, and summarize the main controversies associated with sleep habits.

mos82599_04_c04_101-134.indd 101 2/11/16 8:19 AM

102

Prologue

Chapter Outline

Prologue

4.1 Variations in Birthing Practices Birthing Methods and Delivery Options Investigating Cultural Variations

4.2 Stages of Labor Stage 1 of Labor: Dilation and Effacement of the Cervix Stage 2 of Labor: Delivery of the Baby Stage 3 of Labor: Delivery of the Placenta Perinatal Complications Cesarean Section

4.3 Newborn Assessment

4.4 Preterm, Low-Birth-Weight, and Small-for-Date Infants Low-Birth-Weight and Small-for-Date Infants Very-Low-Birth-Weight and Extremely-Low-Birth-Weight Infants Intervention Strategies

4.5 Early Infant Care Bonding Peripartum Depression Family Members and Caregiving Partners

4.6 Breast Versus Formula Feeding

4.7 Infant States of Arousal and Behavioral Reflexes Infant States of Arousal Sleeping and Bedsharing Sudden Infant Death Syndrome (SIDS) Reflexes

Summary & Resources

Prologue When my wife went into labor with our first-born child, we were in a parking lot ready to go into a home improvement store—neither of us remembers what we were going to buy. The first contraction was painful, so what did we do? We went to an electronics store 15 minutes away to buy a backup battery to make sure that we could record the events at the hospital! (The salesperson asked my wife when she was due. When she replied, “I just started labor,” we moved quickly to the front of the checkout line.) We then went home so that my wife could take a shower and I could call my 30 clients to let them know that my three-week break would be starting the next day. We left for the 40-minute ride to the hospital about 90 minutes after the first contraction, fully confident that my wife would not be giving birth on the highway. Indeed, she remained in labor well after arriving at the hospital and our son Max was born a number of hours later.

mos82599_04_c04_101-134.indd 102 2/11/16 8:19 AM

103

Section 4.1 Variations in Birthing Practices

Labor is rarely as simple as it appears on TV or in film, where the amniotic sac (“the water”) breaks, there is a mind-numbing contraction, and 22 minutes later out pops a clean baby. Though labor is usually more protracted, it is also a lot less chaotic than is often depicted. In this chapter, we look at the reality of childbirth and perinatal development (the weeks before and after delivery), while maintaining a scientific view of the process of labor. We will begin with potential birthing options, including choices in birthing professionals, and then discuss global issues that affect newborns and their parents. We conclude the chapter with an exami- nation of the many built-in competencies that enable newborn infants to explore their world.

4.1 Variations in Birthing Practices In 1900, nearly every baby in the United States was born away from a hospital. One hundred years later, the proportion of out-of-hospital births had dropped to below 1%. Giving birth changed from a natural family experience to a medical event that needed to be controlled. Birthing traditions have continued to evolve. Over the last decade, the number of women in the United States who gave birth at home has increased by over 20%. Though a substantial rise, this proportion still represents only 1.36% of all births. Trends may be changing, but nearly 99% of all U.S. births still occur in hospitals, usually supervised by physicians (Mac- Dorman, Declercq, & Mathews, 2011; MacDorman, Mathews, & Declercq, 2014).

This pattern is not the same through- out the world. The Netherlands has the highest rate of at-home births in the developed world, at 23%. However, in contrast to the United States, at-home births in the Netherlands declined steeply, by 35%, during the decade that ended in 2010 (Brouwers et al., 2013). In developing nations, where Western medical practices are rare, birthing practices have not changed much over many generations; women rely almost exclusively on assistants who lack traditional medical training. “Hospitals” are often little more than ordinary community buildings that are held in reserve for unsophisticated emergency care.

Even though the vast majority of births in the United States continue to occur in hospitals, other circumstances of deliveries have slowly begun to change. Two generations ago, women were mostly isolated in the delivery room. Today, active participation by supportive part- ners, and even multiple friends and family members, has become routine. In addition, nurses and certified midwives who are trained in the care of pregnant women and birth practices are gradually increasing their presence in the hospital delivery room. Uncomplicated vaginal births attended by certified midwives (0.7%) and certified nurse-midwives (11.9%) recently reached an all-time high in the United States, at 12.6%. And in technologically advanced Asian

iStock/Thinkstock

In the United States, the percentage of women who give birth in hospitals is nearly 99%.

mos82599_04_c04_101-134.indd 103 2/11/16 8:20 AM

104

Section 4.1 Variations in Birthing Practices

and European countries, midwifery occurs at three to four times that rate (Declercq, 2015). As access to physicians becomes increasingly regimented, perhaps families look to midwives for more personal attention and comfort. However, unlike other countries, national licensing for certified midwives who are not also licensed registered nurses does not exist. Therefore responsibilities and supervisory restrictions for certified midwives vary from state to state.

Large-scale research on the effectiveness of midwifery offers contradictory findings, such as a reduced chance of internal bleeding among mothers, but a higher risk of early infant death (e.g., de Jonge et al., 2013; Wax et al., 2010). From a scientific standpoint, midwifery research does not offer an unequivocal recommendation. However, debatable findings may be due to poorly matched comparison groups. That is, factors related to health or education may con- tribute to more variation than the location of the birth. Indeed, the majority of studies suggest no adverse effects on neonates (children younger than one-month of age) and consistently positive outcomes on maternal mental and physical health (Zielinski, Ackerson, & Low, 2015). Despite the controversies, midwifery appears to be an important bridge in providing skilled services in poorer countries, where a severe shortage of birthing professionals exists (Fau- veau, 2011).

As a kind of compromise between home and hospital births, a newer model includes special- ized birthing centers, sometimes as an annex to a hospital. They appear as a blend of a hotel and a community health clinic. Well-trained staff is usually present, but immediate access to emergency medical treatment often is not. These kinds of alternatives forecast greater accep- tance of doulas. Whereas midwives primarily function as medical professionals to assist dur- ing the birthing process, doulas provide supplementary educational, emotional, and physical support throughout the pregnancy as well as the postpartum period. In many ways, doulas act like a “best friend” and coach for new mothers, and some (in lieu of a midwife or doctor) provide assistance during birth as well. Historically, doulas were the norm until 20th-century medicine began to isolate births in hospitals (Dundek, 2006). However, the tide has begun to turn back toward less traditional medicine in the United States, partly because of the influx of immigrants and the resulting melting pot of cultures.

One such example comes from Minnesota. Because of the civil unrest in Somalia beginning in 1991, a large number of refugees settled in the Twin Cities area. Preg- nant Somali women are traditionally attended to by doulas, so in 2002 a pilot program was implemented in order to meet their different cultural needs. Outcomes among those who were attended by a doula were com- pared to those who were not. Among 123 women, the

support provided by doulas during and after the birth process led to fewer medical inter- ventions during delivery and higher overall satisfaction with the birth experience (Dundek, 2006). The findings in Minnesota are consistent with more recent studies that show overall healthier outcomes for infants and more positive birth experiences for mothers, even when doulas are trained volunteers (e.g., Cattelona, Friesen, & Hormuth, 2015; Gruber, Cupito, & Dobson, 2013; Kozhimannil, Hardeman, Attanasio, Blauer-Peterson, & O’Brien, 2013). Results from an international analysis found research on doula care is beset by the same kinds of methodology weaknesses that affect midwifery research (Steel, Frawley, Adams, & Diezel, 2015). Despite the lack of consensus, it appears that the emotional and financial benefits of including doulas as part of the professional health care team are significant and may become an attractive option in health care.

Critical Thinking

Investigate and then compare and con- trast midwives and doulas. What are the advantages for each?

mos82599_04_c04_101-134.indd 104 2/11/16 8:20 AM

105

Section 4.1 Variations in Birthing Practices

Birthing Methods and Delivery Options Regardless of any particular medical and support staff, there are a number of different birth- ing methods and delivery options that are practiced. Throughout the world, women use vastly different non-pharmacological pain management procedures, even when there is simi- lar knowledge of techniques (Robertson & Johansson, 2010). In the Lamaze method, which receives the most attention in the United States, women attend classes with a partner, usu- ally the father, who serves as coach. The idea of Lamaze is to make delivery as natural and as comfortable as possible, regardless of circumstances. The coach learns to guide breathing and muscle relaxation exercises during labor and delivery. Research consistently demonstrates that the techniques and support initiated by the Lamaze method is associated with less medi- cation, easier labor, and a more positive birth experience (Lothian, 2011; Xiang & Xiuhong, 2014).

The supine (lying on back) position used in Lamaze and other methods is not necessarily medically indicated. The birthing position is often dictated by culture. For instance, in the Republic of Tanzania about half of women give birth at home. Nearly always they use an upright position during labor, including squatting. Women who are supported by a partner in an upright position report less pain than those who give birth lying on their backs (Eberhard, Stein, & Geissbuehler, 2005). These positions allow women to visually confirm the infant’s emergence and adjust the birthing process accordingly. However, the cultural norm through- out the world for the half of women who give birth in medical facilities is the supine position (Gupta, Hofmeyr, & Shehmar, 2012).

Other, less commonly publicized birthing methods include gentle births “without violence” (especially in water), popularized by Frederick LeBoyer, and self-hypnosis. These methods are intended to reduce pain and to be less traumatic for the infant. However, some research indicates that infants born in water are actually less healthy immediately after birth, though there is no difference at 5 minutes postpartum (Menakaya, Albayati, Vella, Fenwick, & Ang- stetra, 2013). Recently, more women have begun to use hypnosis during labor. This technique is sometimes called the Mongan method but is formally referred to as HypnoBirthing (Mon- gan, 1989). The goal in this method is to relax during the birth process.

Investigating Cultural Variations As noted in the opening to this chapter, we have only recently begun to understand best preg- nancy and birthing practices from a scientific standpoint—and we are still learning. We know, for instance, how to protect mothers and their babies from most hospital-borne infections,

Activity How much importance should be given to financial considerations when deciding on the ben- efits of employing a doula? Answer this question first, and then see Chapple, Gilliland, Li, Shier, & Wright (2013). Analyze the information from the position of a public health care advocate, as a pregnant woman, and then as a scientist. You can read the study on the WMJ website (https://www.wisconsinmedicalsociety.org/_WMS/publications/wmj/pdf/112/2/58.pdf ).

mos82599_04_c04_101-134.indd 105 2/11/16 8:20 AM

https://www.wisconsinmedicalsociety.org/_WMS/publications/wmj/pdf/112/2/58.pdf

106

Section 4.1 Variations in Birthing Practices

but there is still considerable debate about ideal birthing practices. Birthing practices depend alternately on local customs, physician preferences (often based on tradition), and proximity of technology. Adding to the ambiguity are various cultural practices that have not been as widely investigated as traditional Western practices. Some, however, are without scientific or practical merit and are instead rooted in cultural beliefs. For example, the Cuna tribe in Pan- ama believes a spiritual power called Muu lives inside the uterus and must release the child. Difficult births are blamed on Muu’s uncompromising grip as well as spirits that congregate at the vaginal opening. In these circumstances, a shaman (medicine man) is summoned to provide song that will release Muu’s grip and dispose of the spirits (Lévi-Strauss, 1977; Mjönes, 2010).

Although there is often a romanticized stereotype that the alternative tradi- tions of some rural societies produce successful outcomes, it is instead com- mon for poor practices to be passed down from generation to generation. For instance, in rural India where rates of neonatal death are among the highest in the world, a poorly paid, untrained attendant called a dai does little more than cut the umbilical cord with a sometimes-sterile instrument. Malay women are discouraged from crying out; drawing attention to the circumstances of childbirth shames them. As such, there is little emotional support during and immediately after childbirth. For several weeks mothers are kept partially isolated so they will

not contaminate others with the shame of blood and childbirth (van Teijlingen, Lowis, McCaf- fery, & Porter, 2004).

Other traditions are simpler, but remain without scientific validity. For instance, in some cul- tures it remains taboo for pregnant or new mothers to eat certain foods when there is no scientific basis for their exclusion. In some rural parts of Gambia, pregnant women are dis- couraged from eating certain meats because of the belief that their children will acquire the food’s characteristics: Children would be lazy like a crocodile or fat like a cow if mothers were to consume those foods (Pérez & García, 2013). In Egypt, women avoid tomatoes and onions after delivery because of the mistaken belief that those foods will cause babies to cry; many also believe that junk food causes cancer and stewed vegetables and meats decrease milk production when lactating (Kavle et al., 2014). Ironically, adhering to food taboos often leads to health complications, including inadequate weight gain and anemia.

In other cases, women are prescribed herbal teas, and there are plenty of stories in the United States and elsewhere about eating a particular meal to induce labor or make the birth process easier. Although certain foods, drinks, “spiritual” opportunities, and rituals and customs may not have any direct effects on labor, they can provide a placebo effect and provide a sense of calm, psychological wellness, and reduced pain (Crow et al., 1999).

Kike Calvo/National Geographic Magazines/Getty Images

The Cuna tribe in Panama fosters the cultural belief that a spiritual power called Muu is at fault for difficult births.

mos82599_04_c04_101-134.indd 106 2/11/16 8:20 AM

107

Section 4.2 Stages of Labor

4.2 Stages of Labor Though customs and traditions surrounding pregnancy, childbirth, and postnatal care vary greatly, the birth process has of course remained static. But through the stages of labor, the birth experience is quite an individualized process, with individual experiences. There are three distinct stages of labor: dilation and effacement of the cervix, delivery of the baby, and delivery of the placenta. The first physical sign that birth is approaching often occurs when the baby “drops” lower into the uterus (sometimes called lightening) up to 3 weeks before labor begins. With the guidance of hormones, labor nears and the mucus plug that sealed the cervix may be discharged (the bloody show), especially if the cervix has begun to dilate. When the amniotic sac ruptures (the “water breaks”), the fetus is left without the protection pro- vided by the amniotic fluid. At that point, the birthing process is imminent. If labor does not begin at that time, or if a woman is significantly beyond her due date, labor can be medically induced with synthetic oxytocin, which will accelerate labor. Oxytocin is naturally produced at low levels throughout pregnancy and is generally administered without presenting any complications (Alfirevic, Kelly, & Dowswell, 2009).

Although the first stage of labor begins when purposeful contractions of the uterine muscles begin the process of pushing the baby through the birth canal, the uterus is active throughout the pregnancy. The activity is probably a way for the body to stimulate blood flow and pre- pare for childbirth by increasing muscle tone (Blackburn, 2012). Early on, these contractions are almost always undetectable. Toward the end of the second trimester, painless Braxton Hicks contractions may occur, though not all women will notice them. This development is sometimes called false labor because there can be mild cramping. However, continuing to refer to these developments in this way may prevent women from recognizing more serious

Although industrialized areas have been criticized for medicalizing childbirth, clearly there are immense advantages. And just like Western medicine, unedu- cated traditional practices also change. Lao PDR, a poor country where the vast majority of families continue to live in rural areas, is one example. Over the last genera- tion, there has been a dramatic shift from forest-based to home-based delivery; there has even been an uptick in utilization of remote clinic services for complicated deliveries (Alvesson, Lindelow, Khanthaphat, & Laflamme, 2013; United Nations Develop- ment Programme [UNDP], 2014). With increased communication, other generational changes have taken place as well. One analysis found that because of better information, many ineffec- tive postnatal customs that were present before 1950, like those relating to keeping women isolated, have disappeared (Eberhard-Gran, Garthus-Niegel, Garthus-Niegel, & Eskild, 2010).

Section Review Why is it important to understand cultural variations in birthing practices? Consider this ques- tion, and describe some of the economic and cultural variables that impact birthing practices.

Critical Thinking

What types of historical changes in post- natal customs have occurred in the United States since 1950? What kinds of changes do you anticipate in the future?

mos82599_04_c04_101-134.indd 107 2/11/16 8:20 AM

108

Section 4.2 Stages of Labor

signs of preterm labor, delaying necessary medical attention (MacKinnon & McIntyre, 2006). Unlike preterm labor, Braxton Hicks contractions are usually not painful, do not intensify over time, and perhaps most pointedly, they occur at irregular intervals. On the other hand, women should seek immediate medical attention when warning signs of preterm labor appear, such as a regular pattern of abdominal tightening (even if they are not painful), increased vaginal discharge, abdominal pain or pressure (especially when pressing on the abdomen), and dull or rhythmic pain in the lower back (Behrman & Butler, 2007; Blackburn, 2012).

Stage 1 of Labor: Dilation and Effacement of the Cervix The first stage of childbirth occurs when more acute contractions begin. The muscles of the uterus literally begin to contract in order to push the baby out. Contractions start out 10–20 minutes apart and last 10–20 seconds; the contractions get closer and closer together, last longer, and usually become more painful. Just before birth, contractions might be 2 minutes apart and last up to a minute. Uterine contractions cause dilation (enlargement of the cervi- cal opening) and effacement (a thinning of the cervix) so that the baby can pass through the birth canal. Stage 1 of labor typically lasts between 8 and 12 hours for first-time mothers and about 4 to 8 hours for subsequent births (Littleton-Gibbs & Engebretson, 2013; Zhang, Tro- endle, & Yancey, 2002). When contractions are at their peak and the cervix opens completely to about 4 inches, or 10 centimeters, transition has occurred, signaling that stage 2 of labor is ready to begin (Figure 4.1).

Figure 4.1: Effacement and dilation of the cervix during stage 1 of labor

When the cervix is fully dilated to 10 centimeters and effaced (thinned), the baby is ready to pass through the birth canal.

Alila Medical Media/Shutterstock.com

Stage 2 of Labor: Delivery of the Baby After the cervix is fully dilated, the baby’s head appears at the vaginal opening, a period called crowning. Powerful contractions push the baby through the birth canal. This stage may last an hour or more, but like stage 1 it is usually shorter during subsequent births than during a woman’s first. Size of the fetus and the maternal pelvis, force of the contractions, anesthesia,

mos82599_04_c04_101-134.indd 108 2/11/16 1:00 PM

109

Section 4.2 Stages of Labor

and extent of maternal pushing can all affect the length of stage 2 labor. During this process, the fetus changes position to accommodate the mother’s posture.

Stage 3 of Labor: Delivery of the Placenta The last stage of labor includes the final contractions that dislodge the placenta (discussed in Chapter 3) from the uterus. This stage is the shortest of the three, lasting between 5 and 30 minutes. In a full-term pregnancy, the placenta may be 1.5 inches (3.8 cm) thick and weigh up to 2 pounds (907 grams). The placenta is sometimes retained, causing postpartum hem- orrhage (bleeding). This occurs in about 5% of deliveries and remains the leading cause of maternal complications and maternal mortality worldwide; the problem is especially pro- nounced in developing countries (Urner, Zimmermann, & Krafft, 2014). Therefore, expelling the placenta is an important part of the birth process. Its expulsion can be allowed to occur naturally (passive management), with maternal effort, or it can be actively managed with drugs, with massage, through deferred clamping or cutting of the umbilical cord, and by pro- moting breastfeeding soon after birth (Littleton-Gibbs & Engebretson, 2013). Active manage- ment is now the standard for care (Urner et al., 2014).

With prolonged retention, it is manually detached from the uterine wall, but there is a higher risk of blood loss and further complications. In seminal research from Combs and Laros (1991) of over 12,000 births, it was found that the risk of hemorrhage was accelerated after 30 min- utes of being retained. But more recently, investigators noted that complications increased significantly as early as 10 minutes after delivery of the baby and identified the 18-minute mark as a critical cut-off point (Magann et al., 2005). Recognizing that removal of the placenta is a complicated—and as yet unsolved—problem, there is no worldwide consensus on best practices. Doctors in the United States are encouraged to follow the guidelines of the World Health Organization, which recommends waiting 60 minutes if there are no signs of severe bleeding. The recommendation in the United Kingdom is after 30 minutes of active manage- ment; elsewhere in Europe, recommendations range from less than 30 minutes to over 60 minutes (Deneux-Tharaux et al., 2009, National Institute for Health and Clinical Excellence [NICE], 2014; WHO, 2007).

Perinatal Complications Sometimes the umbilical cord is wrapped around the baby’s neck or is in a position where contractions severely restrict or cut off blood flow to the cord. The result is birth asphyxia, which occurs when the brain experiences oxygen deprivation. When oxygen or blood flow is restricted, the baby experiences hypoxia, or limited oxygen levels; when the muscles and brain of the baby are completely deprived of oxygen through blood flow, it is called anoxia. Birth asphyxia can result in brain damage or death, but immediate surgical intervention often prevents permanent damage when equipment is available. In less developed countries, birth asphyxia and other birth traumas remain a leading cause of death and disability, account- ing for about 2 million, or one in five, deaths per year among children under age 5 (Lopez & Mathers, 2006).

Infections and pneumonia are also significant risks where medical care is limited (WHO, 2015d). In India, for instance, where nearly one third of all reported perinatal deaths world- wide occur, almost as many children die each of these two causes as birth asphyxia (Gol- ubnitschaja et al., 2011; WHO, 2015d). Among other complications, malnutrition and poor healthcare among pregnant women leads to underdeveloped fetal organs and preterm births.

mos82599_04_c04_101-134.indd 109 2/11/16 8:20 AM

110

2000

2005

2011

Per 100 live births

Ic el

an d

Ne th

er la

nd s

Sw ed

Es to

ni a

Is ra

Fr an

De nm

ar k

UK Sp

ai n

Ca na

Ire la

*O EC

D 24

Au st

ria

G er

m an

y US

Au st

ra lia

Ko re

a Ita

ly Ch

ile

Tu rk

M ex

ico

Section 4.2 Stages of Labor

Birthing environments in these poorer areas often lead to increased risk of infection, and infants are less able to fight them off. Underdeveloped lungs face a similar risk. As with birth asphyxia, education has a considerably significant effect in reducing these perinatal compli- cations (Golubnitschaja et al., 2011).

Cesarean Section Another birth complication occurs when the fetus is in a breech position. This condition, whereby a fetus’ buttocks or feet are positioned first, is not uncommon. When the baby is in this position, a vaginal delivery is difficult or impossible, and can cause birth asphyxia if completed. Although a proportion of breech vaginal deliveries can be achieved safely, in the United States and other countries, doctors usually opt for surgical procedure called a cesar- ean section (C-section). In this procedure, the baby is delivered by an incision through the abdomen and uterus. Though this procedure has become somewhat routine in the United States and elsewhere, cesarean deliveries are nevertheless major surgical interventions that require many weeks from which to fully recover. Mothers remain hospitalized for 4 or more days and cannot easily care for their newborns without substantial assistance.

In sharp contrast to worldwide trends, a task force of the World Health Organization in 2014 concluded that maternal and newborn mortality rates do not necessarily improve when cesarean rates exceed 10%. This conclusion follows a 1985 recommendation that “there is no justification for any region to have a cesarean section rate higher than 10–15%” (WHO, 2015a, p. 55). Despite these findings, rates continue to rise around the world. Among middle and upper income countries within the Organisation for Economic Co-operation and Develop- ment (OECD), the average rate of C-sections is 27%. Within this economically advantaged group, Mexico has the highest rate of 49% (see Figure 4.2).

Figure 4.2: Cesarean deliveries, selected years and countries

A cesarean section is a major surgical procedure. Though the reasons for electing to undergo the surgery may vary, global rates of cesarean deliveries are continuing the rise overall.

Source: Adapted from OECD. (2013). Health at a glance 2013: OECD indicators. OECD Publishing.

2000

2005

2011

Per 100 live births

Ic el

an d

Ne th

er la

nd s

Sw ed

Es to

ni a

Is ra

Fr an

De nm

ar k

UK Sp

ai n

Ca na

Ire la

*O EC

D 24

Au st

ria

G er

m an

y US

Au st

ra lia

Ko re

a Ita

ly Ch

ile

Tu rk

M ex

ico

mos82599_04_c04_101-134.indd 110 2/11/16 8:20 AM

111

Section 4.2 Stages of Labor

However, rates are exceptionally high in other countries as well. The Dominican Republic and Brazil’s are highest in the world at 56% (WHO, 2015d) (see Table 4.1). The excess proce- dures consume a disproportionate share of global medical and economic resources. In fact, the cost of “excess” C-sections exceed “needed” C-sections by a factor of more than 5 (Gib- bons et al., 2010). As a result, high rates of C-sections create a barrier to overall health care access. Finally, many countries with rates that are substantially less than 10% can signifi- cantly improve birth outcomes by increased training of medical personnel and investing in modern medical facilities.

Table 4.1: Births by cesarean section for selected countries, 2007–2014

Country Births by cesarean section (%)

Minimum country value ,1

South Sudan ,1

Congo 6

Haiti 6

Russian Federation 7

Philippines 9

Namibia 14

Netherlands 16

Iceland 18

Median country value 19

Japan 19

Israel 20

France 21

Armenia 23

China 27

Viet Nam 28

Nicaragua 30

Germany 32

USA 33

Republic of Korea 37

Turkey 37

Mexico 46

Iran (Islamic Republic of ) 48

Cyprus 52

(continued)

mos82599_04_c04_101-134.indd 111 2/11/16 8:20 AM

112

Section 4.2 Stages of Labor

Country Births by cesarean section (%)

Egypt 52

Brazil 56

Dominican Republic 56

Maximum country value 56

Source: Adapted from World Health Organization [WHO]. (2015). World Health Statistics 2015. Global Health Observatory (GHO) data. Geneva, Switzerland: World Health Organization (Part II, page 90).

While it has long been suggested that maternal choice is a primary driver of cesarean deliver- ies, physicians have not always accurately documented rationale for performing the surgery. Recent prospective data from over 30,000 births indicate that only 8% of the decades-long increase in C-sections is due to women who choose to schedule their births (Barber et al., 2011). Instead, over half of doctors cite slow labor progress and concerns about fetal status as reasons for cesarean deliveries. Furthermore, this determination is often done during the sec- ond stage of labor, well before mothers begin pushing. Other reasons for C-sections include mothers carrying twins; these mothers previously had higher rates of vaginal deliveries. As other reports do, the study’s authors note that different rates help us weigh the costs and benefits of higher and lower rates of C-sections.

From the infant’s standpoint, there are potentially fewer birth complications from cesarean section compared to vaginal delivery; it is also more difficult to legally attribute birth defects to a cesarean delivery than to a vaginal delivery. Consequently, the increased threat of law- suits following vaginal deliveries has contributed to a yearly rise in cesarean deliveries in the United States from 21% in 1996 to a peak of 33% in 2009. The rate has since stabilized around that level (Martin et al., 2015). Moreover, delivery method may be influenced more by a doc- tor’s specialty (e.g., surgery) rather than clear medical necessity (Aliaga et al., 2013; Reddy et al., 2012). Children born by C-section have been found to be marginally higher risk for asthma, autoimmune diseases, type 1 diabetes, and a higher prevalence of allergic reactions (Neu & Rushing, 2011). Because these conditions are increasing in general, it is difficult to determine the extent to which cesarean deliveries contribute to negative outcomes. While many have suggested there is a significant association between C-sections and various adverse health outcomes, as yet there is no consistent support for these conclusions (e.g., Leung, Li, Leung, & Schooling, 2015; Robson, Abdel-Latif, & Westrupp, 2015).

Section Review Explain the stages of labor. Make sure to describe distinct processes and indications to per- form a cesarean section.

Table 4.1: Births by cesarean section for selected countries, 2007–2014 (continued)

mos82599_04_c04_101-134.indd 112 2/11/16 8:20 AM

113

Section 4.3 Newborn Assessment

4.3 Newborn Assessment Regardless of delivery method, a quick evaluation of the newborn’s health is typically assessed using the Apgar scale, devised by Dr. Virginia Apgar in 1953. According to the Apgar scoring system, infants are assessed on five objective signs: appearance, pulse, grimace, activity, and respiration (APGAR), as outlined in Table 4.2 (Apgar, 1953). Measuring the same five dimen- sions, modern health care professionals also refer to the mnemonic “how ready is this child” (heart rate, respiration, irritability, tone, color). Among babies with darker skin, color is not pink, but ability to oxygenate extremities is still noticeable on the hands and soles of the feet. A score of 7 to 10 indicates a healthy condition, 4–6 indicates some medical intervention is necessary, and a score of 3 or lower indicates the possibility of long-term neurological conse- quences if immediate medical interventions are postponed. Infants are assessed at 1 minute and at 5 minutes after birth. A score of 10 is relatively rare at 1 minute, so new parents should not be alarmed with a less-than-perfect score.

Table 4.2: Apgar scale

Observation Score

0 1 2

Heart rate Absent , 100 beats per minute . 100 beats per minute

Respiratory effort No breathing Slow, shallow breathing; weak cry

Regular breathing; good cry

(Reflex) irritability None Some response Vigorous response

(Muscle) tone Limp Some flexion of arms and legs Active motion of arms and legs

Color (oxygenation) Blue or pale Pink body, blue arms or legs Completely pink; pink hands and soles of feet for dark- skinned babies

Source: Adapted from Apgar, 1953.

The Apgar scale is also frequently used in research to compare variables like obstetric practices, the stress- ors of anesthesia, or different delivery outcomes. For instance, in Apgar’s original research, when mothers were under general anesthesia, their infants had an average Apgar score of 5.0; when mothers were given a spinal anesthetic, the Apgar average was 8.0. These findings led to a near-elimination of the use of general anesthesia under ordinary circumstances. Addition- ally, cesarean deliveries in general are associated with lower Apgar scores, even when vagi- nal deliveries become complicated by instrument delivery or the fetus’s turning to a breech position (Atanasova, Slavkova, Yonov, & Valkova, 2012). These assessments therefore remain instrumental in medical care.

Critical Thinking

Offer an explanation for why C-sections are associated with lower Apgar scores that is supported by factors other than the effects of the procedure itself.

mos82599_04_c04_101-134.indd 113 2/11/16 8:20 AM

114

Section 4.4 Preterm, Low-Birth-Weight, and Small-for-Date Infants

4.4 Preterm, Low-Birth-Weight, and Small-for-Date Infants More than any other factor, the gestational age of a fetus is perhaps the most important pre- dictor of survival and subsequent infant health. Full-term infants in the United States and other developed countries weigh, on average, more than 7 pounds (3,200 grams) and are about 20 inches (51 cm) long. In the United States, the rate of preterm births has declined for nearly a decade, and now stands at 11.4%, down from a peak of 12.8% in 2006 (Martin et al., 2015). As noted in Chapter 3, infants born early or undersized have a much higher risk of short-term and long-term disabilities and death. Infants born even a few weeks early have substantial differences in health risks (Mathews & MacDorman, 2013). In order to compare research outcomes that lead to consistent, optimal treatment, we differentiate among infants born in typical circumstances and those who are born with less-than-ideal size.

Low-Birth-Weight and Small-for-Date Infants About 8% of newborns weigh less than about 5.5 pounds (2,500 grams), and are classified as low-birth-weight infants (Martin et al., 2015). Most, but not all low-birth-weight infants are born before 37 weeks gestation and are therefore also classified as preterm infants (pree- mies). Babies are classified as small-for-date infants (or small for gestational age) when they weigh less than 90% of infants of the same gestational age. That is, they are at the 10th percentile for weight. Among other complications, low birth weight leads to a higher inci- dence of chronic lung diseases of infancy, permanent damage to the visual system, and death (Lau, Ambalavanan, Chakraborty, Wingate, & Carlo, 2013; Regev et al., 2003).

Very-Low-Birth-Weight and Extremely-Low-Birth-Weight Infants Newborns who weigh less than 3.3 pounds (1,500 grams) are defined as very-low-birth- weight infants. These infants are at highest risk for birth defects and lifelong disabilities. Most very-low-birth-weight infants are preterm, but occasionally a fetus simply does not grow sufficiently in the uterus. They are more susceptible to digestive tract and blood infec- tions, are at higher risk for developmental and learning disabilities, and are especially vulner- able to heart and respiratory disorders (Boghossian et al., 2010). Those born with a weight of between 14.1 ounces and 2.2 pounds (400–1,000 grams) are susceptible to additional com- plications. Compared to others, these extremely-low-birth-weight infants have a markedly higher risk of dying or developing a disability.

Despite several years of declining rates, deliveries that result in low birth weights still vary greatly among racial and ethnic groups (Figure 4.3). For instance, preterm births are nearly 90% higher among black infants than white infants, a disparity that has remained somewhat consistent for more than a decade. Differences in education and access to health care (espe- cially prenatal care) among blacks, Hispanics, and whites account for a significant proportion of the variation. It is likely that cultural attitudes and traditions toward pregnancy and

Section Review Describe what different Apgar scores mean and how they are used.

mos82599_04_c04_101-134.indd 114 2/11/16 8:20 AM

115

1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2013

1990 0

P e rc e n t

Non-Hispanic black

Non-Hispanic white

Total

Hispanic

Section 4.4 Preterm, Low-Birth-Weight, and Small-for-Date Infants

Notably, although babies born before 32 weeks gestation account for only 1.9% of live births, they account for over 53% of all infant mortality, which is 74 times greater than for full-term infants. Though up to half of premature births and low birth weights are unexplained, the increase in maternal health problems related to obesity and diabetes account for a significant proportion of these births (Crane, White, Murphy, Burrage, & Hutchens, 2009; Denison et al., 2013; Harder, Dudenhausen, & Plagemann, 2012). In addition, more frequent use of assisted reproductive technology has led to large increases in multiple births, which in turn produce

childbirth play a role as well. Green (2007) reviews a number of cultural attitudes and beliefs that can impact plan of care, including some groups who believe they should seek prenatal care only when there is a complication. Language is sometimes a barrier to seeking prenatal care as well, as is the fear of repercussions among those in the United States who do not have legal status (Brar et al., 2009).

Figure 4.3: Delivery outcomes among various racial and ethnic groups

In the United States, preterm deliveries rose more than one third over a recent 25-year period. However, new data show four straight years of decline, to approximately 12% of all births. The percentage of preterm deliveries has declined among Hispanics, blacks, and whites and in all age groups (Martin et al., 2015). Despite these gains, there is a high probability that socioeconomic status contributes significantly to group differences.

Source: Martin JA, Hamilton BE, Osterman MJK, et al. Births: Final data for 2013. National vital statistics reports; vol 64 no 1. Hyattsville, MD: National Center for Health Statistics. 2015.

1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2013

1990 0

P e rc e n t

Non-Hispanic black

Non-Hispanic white

Total

Hispanic

mos82599_04_c04_101-134.indd 115 2/11/16 8:20 AM

116

Section 4.4 Preterm, Low-Birth-Weight, and Small-for-Date Infants

more preterm births. The risk of low birth weight among triplets and higher-order multiples is 95% (Martin et al., 2015).

When low-birth-weight and preterm children enter school, they remain at much higher risk for a number of developmental problems. There is a higher incidence of behavioral problems and general cognitive deficits (Olivieri et al. 2012; Tsai et al., 2014). Overall, low-birth-weight and preterm children have a higher than expected rate of placement into special education classes and exhibit a wide range of motor impairments and math and language learning disabilities (Wocadlo & Rieger, 2006, 2008). In addition, the severity and complexity of the learning disabilities is associated with the degree of motor impairment. Not unexpectedly, the severity of these deficits is also positively correlated with the amount of mechanical ventila- tion (respiratory support) a child received as a neonate—more respiratory support during the neonatal period is associated with the likelihood of impairments.

Low-birth-weight and preterm births are also associated with cerebral palsy (CP), the most common childhood disability of movement. Children with CP typically have difficulty with coordination and weak or stiff muscles. These conditions lead to characteristic problems with walking and speech. Among 8-year-old children with CP, 58% walk without assistance, 11% walk with a walker or other device, and 31% have limited or no ability to walk. About 41% also have seizure disorders. In healthy full-term births, an average of 1.1 children out of 1,000 is born with CP. Among low-birth-weight, the figure rises to 6.2 out of 1,000. For very-low- birth-weight, 60 per 1,000 children are affected (CDC, 2015f; Winter, Autry, Boyle, & Yeargin- Allsopp, 2002). Not surprisingly, factors that contribute to low birth weight, including short gestational time and multiple births, are strongly associated with CP as well (Surveillance of Cerebral Palsy in Europe, 2002).

Intervention Strategies The news on infants who are of low birth weight is not all bad. In par- ticular, though trends have recently slowed, new technologies have signifi- cantly reduced the death rate among low-birth-weight infants (Kalkan et al., 2007; Lau, Ambalavanan, Chakraborty, Wingate, & Carlo, 2013). Early inter- vention programs that include emo- tional support (holding and stroking), massage therapy, parental support, and educational support have been found to be successful (Field, Hernandez-Reif, & Freedman, 2004; Hill, Brooks-Gunn, & Waldfogel, 2003; Watson, 2013). Evidence shows that kangaroo care (skin-to-skin contact) should be an integral part of treatment. It has been a valuable strategy in reducing crying, regulating heat and body rhythms, improving cognitive and motor growth, and promoting overall survival and development (Feldman & Eidelman, 2003; Kostandy et al., 2008; Salimi, Khodayarian, Bokaie, Antikchi, & Javadi, 2014; Shrivastava, Shrivastava, & Ramasamy, 2013).

Burger/Phanie/Superstock

Skin-to-skin contact can regulate heat and body rhythms, improve cognitive and motor growth, and promote overall survival and development.

mos82599_04_c04_101-134.indd 116 2/11/16 8:20 AM

117

Section 4.5 Early Infant Care

4.5 Early Infant Care Like preterm infants, full-term infants also need a tremendous amount of care and attention. Initial thoughts about infant care usually revolve around diapering, feeding, and other physi- cal aspects of behavior. But early care encompasses a whole range of cognitive and psycho- social aspects, too. This section explores factors related to the early health and well-being of neonates that affect all developmental domains.

Bonding In contrast to the beliefs of many child developmentalists and psychologists today, in the early to mid-1900s, many physicians and child professionals recommended a “hands off ” approach with children. The reasoning was that attention should be limited so as not to spoil the child. It was not until after World War II that Benjamin Spock published The Common Sense Book of Baby and Child Care (1946) and promoted the radical idea that parents should follow their instincts. He suggested that it was okay—even encouraged—to shower infants with touch and attention. His book sold millions of copies in dozens of languages and forever changed attitudes toward early parenting. The latter half of the century saw professionals with other extreme views. Many suggested that the moments after birth were essential to proper psy- chosocial development. According to them, there is a sensitive period of only a few hours right after birth that initiates bonding, the close physical and emotional contact between parent and child. Medical professionals even blamed disorders like schizophrenia on “schizo- phrenogenic” mothers who did not provide proper early emotional care (Walsh, 1996). How- ever, even as late as the 1960s, women were routinely drugged during childbirth and were not conscious enough to connect immediately with their children. Infants were usually sepa- rated from their mothers after delivery and fathers were generally excluded from the process altogether!

We now know that nearly every baby benefits from physical stimulation, even the most frag- ile. But because of the especially delicate nature of small infants, they are often housed in isolated, protective chambers. To compensate for the largely sterile environment, Field and her colleagues have been instrumental in developing specific interventions strategies (see, e.g., Field, Diego, & Hernandez-Reif, 2010). Techniques involve specific kinds of limb flexing, touching, and massage. As a result, low-birth-weight babies become generally more alert, show greater motor development, and go home earlier. Many hospitals now include volun- teers whose sole job it is to hold and massage these children. More recently, music therapy has joined the list of possible intervention strategies. Several recent studies have suggested that intentional use of lullabies and other live sounds can have a positive effect on a prema- ture infant’s heart rate, sucking behavior, sleep patterns, and calorie intake. An important indirect result of music therapy is that parents of these infants also benefit from reduced anxiety (Loewy, 2015; Loewy, Stewart, Dassler, Telsey, & Homel, 2013; Schwilling et al., 2015).

Section Review Differentiate among preterm, low-birth-weight, and small-for-date infants. Describe potential consequences and intervention strategies for preterm infants.

mos82599_04_c04_101-134.indd 117 2/11/16 8:20 AM

118

Section 4.5 Early Infant Care

Many childcare professionals argue that newborn infants need to feel emotionally close in order for optimal development to take place. However, it is well known that it is not critical for any specific interactions to begin immediately after birth. For example, parents of adoptive children and neonates who are separated

from their parents for medical reasons show patterns of psychosocial development similar to those who are immediately placed with their parents (Myers, 1984). For adoptive chil- dren and their parents, it is probably reassuring to know that research has not supported a critical period for psychosocial development in the minutes, hours, or even days after birth. Although infants benefit tremendously from touch and emotional closeness, immediate post- natal moments do not appear to have a lifelong impact on emotional development. Neverthe- less, bonding is thought of as an important time for new parents. And like the therapy strate- gies mentioned previously, early contact can reduce stress for parents as well as infants (e.g., Loewy et al., 2013).

Peripartum Depression Stress is only one byproduct of having a new child. The excitement of birth is sometimes accompanied by a letdown as hormones and emotions fluctuate from normal levels. Both mothers and fathers may suffer from mood swings commonly referred to as “baby blues” or “maternity blues” as they settle in to sleepless nights and stressful days. Mothers espe- cially may be overcome with emotion and have temporary mood swings. Between 40% and 80% of new mothers experience symptoms, which peak during the first week following deliv- ery (Buttner, Brock, & O’Hara, 2015). Symptoms might include irritability, mild sadness, and disruptions in concentration. For the vast majority of mothers, these feelings go away a few weeks later. While it is estimated that 10–25% of fathers worldwide suffer similar symptoms, like maternal postpartum disorders, a significant number of them may also be associated with other psychiatric disorders (Gressier, Tabat-Bouher, Cazas, & Hardy, 2015; Kim & Swain, 2007).

Previously, physicians and mental health professionals referred to continuing, more severe maternal symptoms as postpartum depression. However, about half of women who suffer post- partum depression experience associated symptoms prior to delivery (Mehta et al., 2014). Therefore, the Diagnostic Manual of the American Psychiatric Association (the DSM-5), refers to this condition as major depressive disorder with peripartum onset. According to the DSM-5, peripartum is the period during pregnancy and up to 4 weeks after delivery, but there is no particular outside consensus for a definitive ending for the postpartum period (O’Hara & McCabe, 2013). The diagnostic change recognizes that depression that is associated with delivery of a child may sometimes have more to do with preexisting depression or anxiety than the specific events following childbirth. That is, perhaps predisposing factors make some women more vulnerable to increased psychological problems (Mehta et al., 2014; Rai, Pathak, & Sharma, 2015). It is estimated that 10–15% of mothers suffer from this prolonged depression during the postpartum period. It is characterized by crying fits, changes in appe- tite, changes in sleep (a lot more or a lot less), a lack of joy, and a feeling of hopelessness (Kim, Epperson, Weiss, & Wisner, 2014). Although cultural differences impact the prevalence and severity of postpartum depression, additional research is needed to understand how these changes occur (Ramadas & Kumar, 2015).

Critical Thinking

Can bonding be a one-way relationship, or does it need to be reciprocal?

mos82599_04_c04_101-134.indd 118 2/11/16 8:20 AM

119

Section 4.5 Early Infant Care

On average, for every one thousand births, one or two women will have a psychotic break. Rarely (approximately 4% of the time), these conditions will result in women killing their infants, as in the case of Andrea Yates in 2001 (Spi- nelli, 2009). Symptoms are typically acute and often appear during the first few days after delivery. Mothers might appear paranoid, have delusions, and show exceptional confusion and dis- organized behavior (Rai et al., 2015). Symptoms ordinarily last from a few days to a few weeks, but need immedi- ate treatment regardless of duration. Like other postpartum disorders, the prevalence of postpartum psychosis is much higher in women with previous symptoms of major depression or psy- chiatric disorders, perhaps up to 100 times greater (Spinelli, 2009).

As a result of depression in the postpartum period, infant care and nutrition are likely to be affected by the mother’s mental state (O’Hara & Wisner, 2014). And infants respond in kind. Evidence suggests they experience more emotional problems, including sadness and anger, and delays in cognitive development (American College of Obstetricians and Gynecologists, 2006; Patel et al., 2012; Tran et al., 2013). Early intervention for postpartum depression is therefore essential. Medical treatment (antidepressant medication) is often prescribed in conjunction with psychological counseling. Although there are not enough studies to make definitive conclusions, some analyses point to the advantage of drug therapy over the moder- ate psychological benefits of counseling (Fitelson, Kim, Baker, & Leight, 2011; Kim et al., 2014; O’Mahena et al., 2012). However, the addition of counseling is necessary so that families can learn coping strategies, such as fathers and other adults providing emotional warmth to the baby. In most cases, short-term treatment is successful.

Family Members and Caregiving Partners Unlike the recent past when fathers were forcibly restricted from entering the labor and delivery room, many men in industrialized countries see themselves as partners during the birth, sometimes even attending all-male prenatal classes (Friedewald, Fletcher, & Fairbairn, 2005). Elsewhere, fathers continue to be excluded from the entire labor delivery process. Research indicates that participation by men during childbirth has a positive effect on deliv- ery outcomes, including the acceleration of labor, reduced need for anesthesia, and lower incidence of both instrumental deliveries and cesarean sections. Their active involvement supports family cohesion and is also associated with positive paternal roles (Hodnett, Gates, Hofmeyr, & Sakala, 2012; Pestvenidze & Bohrer, 2007; Sapountzi-Krepia et al., 2010).

Furthermore, women report that they would like to have their husbands present for comfort and support (Anugwom, 2007; Vehviläinen-Julkunen & Emelonye, 2014). This information

iStock/Thinkstock

Between 10% and 15% of women experience the crying fits, changes in appetite, changes in sleep, lack of joy, and feeling of hopelessness associated with depression during the postpartum period.

mos82599_04_c04_101-134.indd 119 2/11/16 8:20 AM

120

Section 4.6 Breast Versus Formula Feeding

mirrors that of other countries as well, but some cultural norms continue to restrict any benefits that might be afforded greater participation (e.g., Kakaire, Kaye, & Osinde, 2011; Modarres, 2005). In Nigeria and other cultures where spousal participation is traditionally low, there is usually intent to keep fathers physically and emotionally removed. It is ironic that these cultural attitudes restrict participation by fathers, since they acknowledge the impor- tance of mother and child support. In the Nigerian custom of Omugwo, the grandmother gives the baby its first bath in order to show that there is a community of support.

Moreover, the way that families are viewed is dynamic and includes individual variation. Caregiving partners are often unmarried by choice. It is not unusual for mothers, grandmoth- ers, and friends to attend the birth and be an integral part of the perinatal process. The use of birthing centers for uncomplicated deliveries acknowledges that pregnancy and childbirth is increasingly a family affair. These social changes can assist new parents and their babies in the adjustment process.

Section Review How might the initial parent-child relationship be affected by major depressive disorder with peripartum onset? Include examples from each of the three domains of development.

4.6 Breast Versus Formula Feeding The adage “breast is best” has received renewed emphasis as more mothers in the United States have committed to breastfeeding. At the same time, millions have grown up on formula without any apparent disadvantages, which has also allowed fathers and other caregivers to play a larger role. Beginning around the time of the baby boom in the late 1940s, it was thought that formula feeding was in many ways superior to breastfeeding. The leading argument in favor of formula was that parents could control the amount and timing of nutrition. Parents could be assured that their children were well fed by giving them premeasured amounts of formula. The trend toward replacing breast milk with formula continued in the United States until the early 1970s, when it began to reverse.

Today there is consensus among doc- tors and developmentalists that breast- feeding should be pursued whenever possible. Breastfeeding is correlated with increased immune system func- tioning, including significant reduc- tions in the prevalence of asthma; some forms of cancer; and respiratory, diarrheal, and ear infections. There is

Creatas/Thinkstock

Breastfeeding is correlated to a variety of health benefits, including increased immune system functioning, reduced obesity throughout lifespan, and a lower risk of diabetes.

mos82599_04_c04_101-134.indd 120 2/11/16 8:20 AM

121

Early postpartum At 6 months

At 12 months

Exclusively through 3 months

Exclusively through 6 months

100

19 99

20 00

20 02

20 03

20 01

Year of birth 20

04 20

05 20

06 20

07 20

10 20

11 20

P e rc

e n

ta g

100

20 03

Year of birth 20

04 20

05 20

06 20

07 20

10 20

11 20

P e rc

e n

ta g

Section 4.6 Breast Versus Formula Feeding

reduced incidence of obesity throughout the lifespan and a lowered risk of diabetes (AAP, 2012; Amitay & Keinan-Boker, 2015; McNiel et al., 2010). And, after several key forums and research colloquia, the SIDS and Kids National Scientific Advisory Group of Australia con- cluded that evidence had reached a “critical threshold” to support breastfeeding as a spe- cific measure for SIDS risk-reduction (Young, Watson, Ellis, & Raven, 2012). Research also suggests breastfeeding can lead to cognitive advances, perhaps due to the concentration of compounds found specifically in breast milk (AAP, 2012; Ryan & Nelson, 2008; Tanaka, Kon, Ohkawa, Yoshikawa, & Shimizu, 2009). For mothers, breastfeeding has the added advantage of allowing for a faster return to pre-pregnancy weight; though breast milk is not as easily portable as formula, fathers can still benefit from feeding their children when mothers pump breast milk for later use.

In accordance with these findings, the American Academy of Pediatrics (AAP) states that the exclusive consumption of breast milk during the first six months or longer should be the “nor- mative standard” and not simply a lifestyle choice (AAP, 2012). The World Health Organiza- tion states that optimal feeding entails “exclusive breastfeeding” without any additional nutrition, including water (World Health Organization, 2013). In the United States, however, exclusive breastfeeding in the first 3 months is the norm for only about 38% of infants (see Figure 4.4). Although the number of mothers who breastfeed has risen dramatically since the 1970s, gains have slowed considerably since the early 1990s (CDC, 2014b; Ryan, 1997). Women report that it is inconvenient; they do not like the process; they are embarrassed; it interferes with household chores; and they have had to attend to other responsibilities, including childcare, work, and school (Office of the Surgeon General, 2011; Ogbuanu et al., 2009). These reasons have remained fairly consistent throughout multiple surveys.

Figure 4.4: Percentage of U.S. infants who are ever breastfed and those who are

exclusively breastfed through 6 months

The number of mothers who breastfeed their infants has risen dramatically since the 1970s. However, the number of mothers who follow APA recommendations and breastfeed exclusively for at least 6 months remains at 16%, well below the target rate of 50%.

Source: National Immunization Survey (2014).

Early postpartum At 6 months

At 12 months

Exclusively through 3 months

Exclusively through 6 months

100

19 99

20 00

20 02

20 03

20 01

Year of birth 20

04 20

05 20

06 20

07 20

10 20

11 20

P e rc

e n

ta g

100

20 03

Year of birth 20

04 20

05 20

06 20

07 20

10 20

11 20

P e rc

e n

ta g

mos82599_04_c04_101-134.indd 121 2/11/16 8:20 AM

122

Section 4.6 Breast Versus Formula Feeding

One major confounding variable in this research is how much of the breastfeeding advan- tage is due to human milk consumption and how much to the type of parent who chooses to breastfeed. Among women who breastfeed, there are significant differences in SES, the home environment, and parental intelligence. It follows that SES has an effect on how parents treat potential illnesses, including their identification and treatment, and how well their chil- dren perform cognitively. As Figure 4.5 shows, breastfeeding varies as a function of income level, education, and age, which are associated with developmental outcomes independent of breast versus formula. Almost two thirds of low-income women are not aware that breast milk protects against diarrhea; about three fourths of the adult public is unaware that breast milk decreases the chances of a baby becoming ill. Even though breast milk offers a huge financial savings over formula, harried lower income families may instead opt for the short- term convenience of bottles without considering a breast pump.

In developing countries, the issue of breast milk versus formula takes on a different tone, as described in the feature box, “Making Connections: Encouraging Healthy Infants.” There are also many circumstances when breastfeeding either cannot take place or is not indicated. Mothers should not breastfeed when they carry infectious diseases like AIDS or tuberculosis or when they are taking medication that can be ingested through breast milk. In addition, adoptive parents and those who have physical difficulties or insufficient breast milk also do not breastfeed. On the other hand, many fathers and others cherish the opportunity to share these new joys. Fathers of bottle-fed babies (whether formula or pumped breast milk) have the advantage of increased participation in feeding, which also allows new parents to decrease the stress associated with having a new infant.

Making Connections: Encouraging Healthy Infants

Due largely to the lobbying efforts of the formula makers, many parents in developing coun- tries have erroneously believed that formula is superior to human milk. In addition, because of poor economic conditions, families will often dilute formula, which means it provides less than optimal nutrition. This problem leads to an estimated 1.5 million deaths annually among formula-fed infants in developing countries (UNICEF, 2013). In response, the World Health Organization (WHO) adopted a code in 1981 calling for a ban on the promotion of formula, especially in the form of free samples given to new mothers in hospitals.

In the 1990s, WHO and UNICEF collaborated on the Baby-Friendly Hospital Initiative (BFHI) to encourage hospitals and birthing centers to provide a plan for mothers to gain the confi- dence and skills needed to breastfeed exclusively. Hospitals and birthing centers receive a “Baby-Friendly” designation by following the BFHI guidelines.

According to UNICEF (2009), after implementing BFHI in China, exclusive breastfeeding rates increased in urban areas from 10% to 47% over 2 years. In Zambia, rates doubled over 5 years; in Nicaragua, breastfeeding rates increased from 47% to nearly 100%, including 39% at the 20-month mark. Unfortunately, however, mothers do not always follow through. Though an alarming 10% of Nicaraguan babies are malnourished, only 31% of them were exclusively breastfed through 6 months. Nevertheless, in the United States and throughout the world, these data suggest a strong relationship between BFHI and an increase in breastfeeding, espe- cially in high-risk populations (Parker et al., 2013).

mos82599_04_c04_101-134.indd 122 2/11/16 8:20 AM

123

P e rc

e n

ta g

e P

e rc

e n

ta g

Total Non-Hispanic white

Non-Hispanic black

Mexican American

Total Non-Hispanic white

Non-Hispanic black

Mexican American

Lower income

Higher Income

P e

rc e

n ta

g e

Ever breastfed Breastfed at 6 months

Breastfed at 12 months

100

College graduate

Some college or technical school

High school graduate

Less than high school

Under 20 years

30 years and older

20–29 years

Section 4.6 Breast Versus Formula Feeding

Figure 4.5: Percentage of infants who are breastfed, by maternal age, race/

ethnicity, and income level

Breastfeeding varies with maternal age, race/ethnicity, income, and education level.

Source: Breastfeeding among U.S. Children Born in 2012, CDC National Immunization Survey.

P e rc

e n

ta g

e P

e rc

e n

ta g

Total Non-Hispanic white

Non-Hispanic black

Mexican American

Total Non-Hispanic white

Non-Hispanic black

Mexican American

Lower income

Higher Income

P e

rc e

n ta

g e

Ever breastfed Breastfed at 6 months

Breastfed at 12 months

100

College graduate

Some college or technical school

High school graduate

Less than high school

Under 20 years

30 years and older

20–29 years

mos82599_04_c04_101-134.indd 123 2/11/16 8:20 AM

124

Section 4.7 Infant States of Arousal and Behavioral Reflexes

4.7 Infant States of Arousal and Behavioral Reflexes Whereas decisions related to nutrition have lifelong consequences, typical characteristics of initial infant behavior are less variable. Young children are hardly a tabula rasa (blank slate) as described by 17th century philosopher John Locke. We are programmed even from con- ception for certain behaviors and characteristics, such as walking, babbling, and expressing emotions. At least some senses operate at a high level beginning right at birth. This section explores emergent sensory systems as well as behaviors that are universal to early infancy.

Infant States of Arousal Neonates cycle through different states of arousal, just like adults. States range from active alertness to quiet, restful sleep (see Table 4.3). But infants also have states of quiet alertness and active sleep. Actively sleeping infants may make faces and appear distressed, but they regularly sequence through these actions. The nervous system becomes increasingly inte- grated as internal forces like hunger and sleep cause changes in activity levels. Infants use internal and external cues to organize behavior. For instance, they use internal hunger cues to modify external behaviors like crying or latching to a nipple. As brain growth becomes more complex, states of sleep and wakefulness change as well.

Table 4.3: Infant states

State Approximate number of hours per day Characteristics

Alert activity 1–4 Infant shows movement, often with rhythmic activ- ity. Eyes are open and bright, with a shining quality.

Quiet alert 2–3 Eyes are open but not necessarily focused. Motor activity is varied.

Drowsiness Up to 4 Infant is relatively inactive. Breathing is regular but more rapid than during sleep. Eyes may open and close intermittently.

Active (irregular) sleep 8–9 Eyes are closed, and breathing is uneven. Infant makes frequent faces, which may include smiles, frowns, grimaces, sucking, and sighs.

Regular (quiet) sleep 8–9 Eyes are closed, and face appears relaxed. Breathing is slow and regular.

Crying Varies as part of alert activity

Baby vocalizes in response to hunger or discomfort, and makes varied motor movements.

Source: From Wolff, 1966, 1987.

Section Review Outline the scientific advantages of breastfeeding.

mos82599_04_c04_101-134.indd 124 2/11/16 8:20 AM

125

Section 4.7 Infant States of Arousal and Behavioral Reflexes

Infants cycle through the five states of arousal, including crying, alert activity, and regular sleep, shown in Table 4.3. In general, parents guide their infants from one state to another. For exam- ple, a crying infant initiates a response from parents, who attempt to transition the child from crying to the quiet alert state. At other times, the infant’s normal state cycle is disrupted. For instance, parents who want to delay sleep for one reason or another may attempt to keep their babies awake when they observe them becoming drowsy. These states occur at regular inter- vals and for regular amounts of time, again indicating a biological basis for their occurrence.

Sleeping and Bedsharing As noted in Table 4.3, neonates sleep for 16–18 hours per day; however, there is substan- tial individual variation. And rather than sleeping “like a baby,” infants actually engage in more discontinuous sleep, with uninterrupted cycles of active and quiet sleep lasting only 2–4 hours (Adair & Bauchner, 1993; Galland, Taylor, Elder, & Herbison, 2012). Active sleep is indicative of REM (rapid eye movement, or dream sleep) and is usually the first part of the sleep cycle (unlike the sleep of older children and adults). REM accounts for up to half of the sleep cycle at birth, then declines to about one third by six months of age. As newborns, infants go through only one or two cycles of active and quiet sleep at a time (Davis, Parker, & Montgomery, 2004). It will take 2–3 months for infant sleep states to be synchronized on a 24-hour cycle, which will increase the duration of sleep time.

Cultural practices also affect infant sleep patterns. On average, 6-month-old children in the Netherlands sleep up to two hours more per day than children in the United States, reflecting that culture’s emphasis on rest and regular habits (Super et al., 1996). Among the Kipsigis in Kenya, infants sleep considerably less, perhaps as little as 12 hours a day (Super, 1990). Kip- sigis children remain physically close to their mothers, cradled against a mother’s back or hip during the day, and are rarely in a horizontal position when awake. When not with their moth- ers, infants share social space with siblings and neighbors and rarely enjoy an undisturbed sleep environment. As a result, these children rarely sleep for longer than 3 hours at a time even at 8 months of age (Super & Harkness, 1986).

In contrast, by 8 months infants in the United States are usually sleeping 6 hours or more at a time (Oskar & Carskadon, 2009). Partly as a remnant on the emphasis on structure in the early 20th century, most parents in the United States almost immediately begin preparing their children to sleep through the night. They try to ensure that their infants are well fed right before begin- ning their extensive, often stressful nighttime routine. Other cultures manage children’s sleeping arrange- ments by bedsharing; that is, sleeping in the same bed as parents. Bedsharing is described as the norm throughout the world, including both less developed countries and those that are technologically advanced, like South Korea (McKenna & McDade, 2005; Mindell, Sadeh, Kohyama, & How, 2010). Because of the relative lack of nighttime stress, rates of full-time bedsharing in the United States have risen from 6.5% to 13.5%, but a substantial number of parents share a bed at least part time (Colson et al., 2013; Krouse et al., 2012).

Critical Thinking

Bedsharing advocates argue that chil- dren will eventually move to their own rooms voluntarily, but many children do not express this need until adolescence. Therefore, in some ways it may remain less stressful to allow children to sleep with their parents and in other ways it may be more stressful. Use this informa- tion to decide when, if at all, you think bedsharing should end.

mos82599_04_c04_101-134.indd 125 2/11/16 8:20 AM

126

Section 4.7 Infant States of Arousal and Behavioral Reflexes

Sudden Infant Death Syndrome (SIDS) The biggest killer of postneonatal infants in the United States and other Western countries is sudden infant death syndrome (SIDS). It is characterized by the sudden “crib death” of seemingly healthy infants during sleep. For centuries, its cause has remained a mystery. It is likely related to the infant’s inability to wake up when there is a buildup of carbon dioxide in the blood. This condition may result from a combination of genetic and environmental factors, including exposure to secondhand smoke and a baby’s sleep position (Athanasakis, Karavasiliadou, & Styliadis, 2011). It is theorized that sleeping in the prone (face down) posi- tion can cause infants to rebreathe exhaled gases or lead to airway constriction. In either case, oxygen deprivation is the result.

The most important factor in the reduction of SIDS risk is attributed to the recommenda- tion that infants be put “back to sleep.” That is, the AAP recommends that infants be placed on their backs when put down to bed rather than on their stomachs or sides (AAP, 2011). Since the original recommendation in 1992, the incidence of SIDS has declined dramatically, as shown in Figure 4.6. (Note, however, that the incidence of SIDS had been dropping prior to the original AAP recommendation.)

Because studies have found the incidence of SIDS to be higher when parents bedshare, the United States Consumer Product Safety Commission continues to stand by its statement that, “The only safe place for babies to sleep is a crib [with] a tight-fitting mattress” (1999, p. 134). The AAP (2011) Task Force on Sudden Infant Death Syndrome agrees. They have twice reaffirmed the need for back sleeping and avoiding soft bedding. On the other hand, the well-known authors of Sleeping with Your Baby: A Parent’s Guide to Co-sleeping suggest that in order to reduce the incidence of SIDS, “babies should never sleep alone” (McKenna & McDade, 2005, p. 134). They attribute the reduced incidence of SIDS in part to the tandem effect of increased breastfeeding and mother-infant bedsharing. Others suggest that until more definitive information is known, room sharing with an adjacent crib is the best com- promise. (Although successful in other ways, it has not yet been successful in increasing the number of women who breastfeed.)

New multinational research conducted across Europe epitomizes the bedsharing controversy. Researchers suggested that 90% of SIDS deaths that involved a shared bed would not have occurred if children were in their own beds, stating that “professionals and the literature should take a more definite stand against bed sharing” (Carpenter et al., 2013). However, part of the reason for professionals to take a more definitive stand is because parents who smoke, drink, or take drugs are not heeding professional advice. Therefore, if everyone adhered to a unified message to avoid bedsharing, it would prevent SIDS among those infants who are at highest risk. For lower risk groups, finding quality evidence that argues against bedsharing remains elusive (Das, Sankar, Agarwal, & Paul, 2014). The bottom line is that for mothers who do not smoke or drink, and who otherwise would not breastfeed, bedsharing would probably be encouraged. On the other hand, if proximity to the baby does not encourage a woman to breastfeed (and evidence shows it does not), then the benefits of bedsharing are equivocal

mos82599_04_c04_101-134.indd 126 2/11/16 8:20 AM

127

M o

rt a li ty

r a te

p e r

1 ,0

0 0 l iv

e b

ir th

0.5

1.5

19 88

19 89

19 90

19 91

19 92

19 93

19 94

19 95

Year

19 96

19 97

19 98

19 99

20 00

20 01

20 02

20 03

20 04

20 05

20 06

20 07

P e rc

e n

t b

a c k s

le e p

in g

19 92

19 93

19 91

19 94

19 95

19 96

19 97

19 98

19 99

20 00

20 01

20 02

20 03

20 04

20 05

20 06

20 07

Year

13 17

26.9

38.6

35.3

53.1

55.7

64.4

66.6

71.6

71.1

72.8

70.1

72.2 75.7

76.1

Section 4.7 Infant States of Arousal and Behavioral Reflexes

(Hauck, Tanabe, McMurry, & Moon, 2015). (The recommendations of the AAP Task Force, the U.K. Department of Health, and the recent UNICEF-UK Baby Friendly Initiative statement, listed in the Additional Resources section at the end of this chapter, are available to download at no cost.)

Figure 4.6: SIDS rate and sleep position, 1989–2006

From 1989 to 2006, as back sleeping increased, SIDS rates decreased.

Source: Adapted from Colson et al. (2009) and Centers for Disease Control and Prevention (2014i).

M o

rt a li ty

r a te

p e r

1 ,0

0 0 l iv

e b

ir th

0.5

1.5

19 88

19 89

19 90

19 91

19 92

19 93

19 94

19 95

Year

19 96

19 97

19 98

19 99

20 00

20 01

20 02

20 03

20 04

20 05

20 06

20 07

P e rc

e n

t b

a c k s

le e p

in g

19 92

19 93

19 91

19 94

19 95

19 96

19 97

19 98

19 99

20 00

20 01

20 02

20 03

20 04

20 05

20 06

20 07

Year

13 17

26.9

38.6

35.3

53.1

55.7

64.4

66.6

71.6

71.1

72.8

70.1

72.2 75.7

76.1

mos82599_04_c04_101-134.indd 127 2/11/16 8:20 AM

128

Section 4.7 Infant States of Arousal and Behavioral Reflexes

Reflexes Though infants are dependent on others for care, infants are born with many capabilities. They have a number of well-developed reflexes and organized sensory responses that are present at birth (and even before). A reflex is an involuntary response to the environment. For instance, the rooting, sucking, and swallowing reflexes are related to feeding and sur- vival. When a newborn’s cheek is stroked, it will turn its head in the direction of the stimulus, open its mouth and search for a nipple. It wants to find a secure “root” to become stable and secure. When an object like a finger or a nipple is placed into the mouth of the infant, the reflexive response is to suck, with surprisingly sustained force. Infants are also born with a reflex that allows them to swallow the liquid they received from the nipple. It is clear that these reflexes are survival mechanisms. There are others, like the Babinski and Moro (startle) reflexes, which may be evolutionary leftovers and are less well understood (see Table 4.4). Most reflexes eventually fade and become voluntary behaviors.

Table 4.4: Examples of newborn reflexes

Reflex Stimulation Response Function Development

Rooting Stroke cheek near the mouth

Baby orients to source of stimulation and makes feeding movements

An adaptive func- tion to find the nipple and aid survival

Disappears at 3 weeks when baby’s head turns voluntarily

Sucking Place finger or nipple in mouth

Strong, rhythmic sucking

An adaptive func- tion to permit feeding

Disappears at 4 months and becomes voluntary

Swallowing Place liquid in mouth

Swallow To gain nutrition Disappears at 4 months and becomes voluntary

Activity One of the frequently cited reasons given by mothers when they choose not to breastfeed is that it is inconvenient. As a way to make breastfeeding more convenient, many experts rec- ommend having infants within arm’s length of where a mother sleeps. This arrangement is designed to follow recommendations regarding the avoidance of bedsharing while simul- taneously increasing convenience. In response, a “Bedtime Basics for Babies” program was launched whereby cribs and safe sleep education were provided for high-risk families who typically have low rates of breastfeeding. Although mothers in the program became more knowledgeable about infant care overall, there were minimal changes in the rates of breast- feeding. (Read the Hauck, Tanabe, McMurry, and Moon (2015) study: http://www.ncbi.nlm .nih.gov/pmc/articles/PMC4405482.) Provide some reasons why this might be, and discuss some ways that participation rate might improve for high-risk groups.

(continued)

mos82599_04_c04_101-134.indd 128 2/11/16 8:20 AM

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4405482

129

Summary & Resources

Reflex Stimulation Response Function Development

Eye blink Expose eyes to bright light or puff of air

Baby quickly blinks or closes eyes

Protects eyes from damaging stimulation

Permanent

Moro (startle reaction)

Expose infant to a sudden “drop- ping” motion or a loud sound

Arms and legs are extended outward, then are pulled back toward body

Perhaps a “left- over,” primitive response to help infant cling to its mother

Fades at 6 months

Grasping (palmar grasp)

Place finger or object in hand

Baby makes fist around object

Probably pre- pares infant for grasping

Weakens at 3 months; disap- pears by 1 year

Stepping Hold baby upright with some tilt and move forward

Walking-like motions with legs

Thought to prepare infant for voluntary walking movements

Fades at 2 months; disap- pears at 4 months

Babinski Stroke the sole of the foot from heel to toes

Big toe curves and others fan out

Unknown Fades at 9–12 months

Section Review What do neonatal behaviors tell us about the developing child and human development overall?

Table 4.4: Examples of newborn reflexes (continued)

Summary & Resources

Chapter Summary While labor and delivery is a universal phenomenon, the experience is completely individ- ual. There are no universally accepted best practices for comfort or efficiency, so methods are often chosen by cultural tradition or personal choice. As is true of pregnancy, a normal labor and delivery is the rule; however, complications may occur that put mother and baby at risk. Partly as a result of increased caution, over the last several decades we have seen significantly greater numbers of cesarean deliveries worldwide.

We have learned a great deal about intervention strategies that occur after delivery as well, including the purposeful use of touch for children born preterm. For most births, early infant care focuses on emotional closeness and regular routines. Early nutrition is also important. Though there is considerable variation by socioeconomic status and ethnic- ity, most women in the United States still fall far short of breastfeeding recommendations. But most children still follow fairly predictable patterns, including infant states of arousal.

mos82599_04_c04_101-134.indd 129 2/11/16 8:20 AM

130

Summary & Resources

Nearly all infants also follow similar patterns of initial motor reflexes. These movements form the basis for more sophisticated physical processes, which are explored in the next chapter.

Summary of Key Concepts Variations in Birthing Practices

• An enormous cultural shift in birthing practices has paralleled the tremendous gains that have occurred in medical knowledge since the beginning of the last century.

• Unlike in other parts of the world, in the United States most babies are delivered in hospitals under the supervision of doctors. Expectant mothers and their partners may use various birthing methods and classes, such as Lamaze.

• Doulas and midwives, which are common outside of the United States, decreased in popularity during the advent of modern medicine but are again becoming more accepted.

Stages of Labor

• The first stage of labor includes dilation and effacement of the cervix. The stage culminates with transition, when the cervix opens completely and contractions peak.

• The second stage of labor is marked by involuntary contractions and delivery of the baby.

• The last stage of labor includes the final contractions that dislodge the placenta from the uterus.

• If fetuses are in breech position or otherwise stressed, a cesarean section is often indicated.

• Experts suggest that a sizeable proportion of cesarean deliveries throughout the world are not medically indicated and contribute to barriers in accessing health care.

Newborn Assessment

• Evaluation of the newborn’s health is typically assessed using the Apgar scale at 1 minute and at 5 minutes after birth.

• The Apgar scale is also used in research to compare birth outcomes across proce- dures and cultures.

Preterm, Low-Birth-Weight, and Small-for-Date Infants

• Risk of death and severe complications rise inversely as a function of birth weight. • Low-birth-weight infants are those that weigh less than about 5.5 pounds (2,500

grams), regardless of gestational age. • Small-for-date infants are at the 10th percentile for weight. • Very-low-birth-weight infants weigh less than 3.3 pounds (1,500 grams). • Infants that weigh between 14.1 ounces and 2.2 pounds (400–1,000 grams) are con-

sidered extremely-low-birth-weight. • Kangaroo care has been successful in promoting overall survival and development of

preterm infants.

mos82599_04_c04_101-134.indd 130 2/11/16 8:20 AM

131

Summary & Resources

Early Infant Care

• The developmental importance of bonding just after birth is not supported by research, though there is little doubt that it can be a fulfilling time for parents and others.

• Some new mothers suffer from major depressive disorder with peripartum onset. This condition is typically characterized by crying fits, changes in appetite, sleep, and activity level, a lack of joy, and a feeling of hopelessness.

• There is convincing evidence that active participation by fathers has a positive effect on delivery outcomes, promotes less pain, and lowers incidence of instrument and cesarean deliveries.

Breast Versus Formula Feeding

• The debate over breast versus formula feeding has received more attention in recent years as WHO and AAP have issued definitive recommendations that mothers should breastfeed whenever possible.

• There are clear demographic differences in the type of women who choose to breast- feed. Encouraging all groups to increase the duration of exclusive breastfeeding remains a challenge.

Infant States of Arousal and Behavioral Reflexes

• Fairly regular infant states of arousal give clues to researchers about how the behav- ior and nervous system of infants become increasingly integrated.

• Bedsharing with infants is common throughout the world. In developed countries, the issue is immersed in controversy.

• SIDS, the biggest killer of postneonatal infants, occurs during the sleep state. • Some research suggests that bedsharing may reduce the incidence of SIDS as well as

provide a more nurturing environment for infants. However, some organizations are concerned about the potential pitfalls of bedsharing.

• Infants are born with a number of automatic responses (reflexes), which transition to become voluntary within the first year of life.

Critical Thinking and Discussion Questions

1. As noted, regulations for certified midwives who are not also nurses varies from state to state. Explore the difference between regulations between two or more states with different regulations. What are the advantages of each set of rules?

2. It is sometimes difficult to rid ourselves of nomenclature that might not be as useful as in the past. For instance, the last two editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) eliminated the diagnosis of postpartum depres- sion in favor of depressive disorder with peripartum onset. This change recognizes that symptoms of depression that occur after delivery may have more to do with preexisting conditions rather than strictly the events following childbirth. How use- ful do you think this change is for scientists, mental health professionals, and the public?

3. What are some steps that can be taken to reduce the incidence of low-birth-weight infants?

4. Refer to Figure 4.2 and Table 4.1. What are some reasons for such widely differing rates of cesarean deliveries worldwide? You can find worldwide data in Part II, page

mos82599_04_c04_101-134.indd 131 2/11/16 8:20 AM

132

Summary & Resources

90, of the World Health Organization’s World Health Statistics 2015, listed in the Addi- tional Resources section. (See the PDF at http://www.who.int/bulletin/volumes /83/6/449.pdf.)

5. For a woman who has had a cesarean section, it is likely to be quite painful for her to cradle her newborn for an extended period of time. What would you advise her if she is concerned that her baby won’t be able to bond with her?

6. Revisit Figures 4.4 and 4.5. What are some possible reasons that the prevalence of breastfeeding varies by ethnicity, age, and income level?

Additional Resources Web Resources

• Global Health Observatory (GHO) data, World Health organization http://www.who.int/gho/publications/world_health_statistics/2015/en/

• International Childbirth Education Association (ICEA) http://www.icea.org/

• Midwives Alliance of North America http://mana.org/

• National Institute of Neurological Disorders, Brain Basics: Understanding Sleep http://www.ninds.nih.gov/disorders/brain_basics/understanding_sleep.htm

• National Institute of Neurological Disorders and Stroke, Cerebral Palsy http://www.ninds.nih.gov/disorders/cerebral_palsy/detail_cerebral_palsy.htm

• Organisation for Economic Co-operation and Development (OECD) http://www.oecd.org/

• PBS.org Life’s Greatest Miracle (streaming video) http://www.pbs.org/wgbh/nova/body/life-greatest-miracle.html

Further Research

• American Academy of Pediatrics [AAP]. (2011). SIDS and other sleep-related infant deaths: Expansion of recommendations for a safe infant sleeping environment [Tech- nical Report]. Retrieved from http://pediatrics.aappublications.org/content/128/5/ e1341.full

• Chapple, W., Gilliand, A., Li, D., Shier, E., & Wright, E. (2013). An economic model of the benefits of professional doula labor support in Wisconsin births. WMJ, 112(2), 58–64. Retrieved from https://www.wisconsinmedicalsociety.org/_WMS/publications/ wmj/pdf/112/2/58.pdf

• Harding, M. (2015, July 27). Reducing the risk of cot death. Patient. Retrieved from http://patient.info/health/reducing-the-risk-of-cot-death

• Hicks, J. B. (1871). On the contractions of the uterus throughout pregnancy: Their physiological effects and their value in the diagnosis of pregnancy. Transactions of the Obstetrical Society of London, 13, 216–231.

• UNICEF UK. (2014, July 3). UNICEF UK statement on draft nice guidance on co- sleeping and SIDS. Retrieved from http://www.unicef.org.uk/BabyFriendly/News -and-Research/News/UNICEF-UK-statement-on-draft-NICE-guidelines-on-co -sleeping-and-SIDS/

• World Health Organization [WHO]. (2015). World Health Statistics 2015. Global Health Observatory (GHO) data. Geneva, Switzerland: World Health Organization. Retrieved from http://www.who.int/gho/publications/world_health_statistics /2015/en/

mos82599_04_c04_101-134.indd 132 2/11/16 8:20 AM

http://www.who.int/bulletin/volumes/83/6/449.pdf

http://www.who.int/gho/publications/world_health_statistics/2015/en/

http://www.icea.org/

http://mana.org/

http://www.ninds.nih.gov/disorders/brain_basics/understanding_sleep.htm

http://www.ninds.nih.gov/disorders/cerebral_palsy/detail_cerebral_palsy.htm

http://www.oecd.org/

http://www.pbs.org/wgbh/nova/body/life-greatest-miracle.html

http://pediatrics.aappublications.org/content/128/5/e1341.full

https://www.wisconsinmedicalsociety.org/_WMS/publications/wmj/pdf/112/2/58.pdf

http://patient.info/health/reducing-the-risk-of-cot-death

http://www.unicef.org.uk/BabyFriendly/News-and-Research/News/UNICEF-UK-statement-on-draft-NICE-guidelines-on-co-sleeping-and-SIDS/

http://www.who.int/gho/publications/world_health_statistics/2015/en/

133

Summary & Resources

Key Terms anoxia Complete oxygen deprivation in the brain or muscles.

Apgar scale A scale used to assess the ini- tial responses of newborns.

birth asphyxia Occurs when the brain of a child being born experiences oxygen deprivation.

bonding The connection that occurs when one human feels emotionally close to another.

Braxton Hicks contractions Usually painless contractions of the uterus that are thought to increase blood flow and prepare the body for childbirth. Incorrectly referred to as false labor.

breech position When the baby is posi- tioned feet or buttocks first, making a vagi- nal delivery dangerous.

cerebral palsy (CP) The most common childhood disability of movement; most often the result of preterm birth.

certified midwives Professionals who are trained and have passed certification exams in the care of pregnant women and birth practices.

cesarean section (C-section) A surgical procedure for removing a baby through an incision in the abdomen.

contractions The contractions of the muscles of the uterus that force the fetus through the birth canal.

crowning The appearance of the baby’s head at the vaginal opening.

dilation The enlargement of the cervix to allow the fetus to pass through the birth canal.

doulas Caregivers who provide educational and emotional support for pregnant women.

effacement A thinning of the cervix prior to birth that allows the baby to pass through the birth canal.

extremely-low-birth-weight infants Infants who weigh less than 2.2 pounds (1,000 grams) at birth.

hypoxia Limited oxygen levels in the brain or muscles.

kangaroo care Skin-to-skin contact with infants.

low-birth-weight infants Infants who weigh less than 5.5 pounds (2,500 grams) at birth.

major depressive disorder with peri- partum onset A potentially serious disor- der characterized by severe symptoms of depression and anxiety during pregnancy and up to 4 weeks after having a child.

neonates The term to describe infants up to 1-month postpartum.

oxytocin A naturally produced hormone that is present at low levels throughout pregnancy and, at higher levels, is associated with contractions. A synthetic version can be medically administered to accelerate labor.

perinatal development The weeks before and after birth.

preterm infants Infants born prior to 37 weeks gestation. Also known as preemies.

reflex An automatic physical response.

small-for-date infants Infants who weigh less than 90% of infants of the same gesta- tional age.

mos82599_04_c04_101-134.indd 133 2/11/16 8:20 AM

134

Summary & Resources

states of arousal Physiological and psycho- logical states of awareness.

sudden infant death syndrome (SIDS) The sudden unexplained death of a healthy infant that occurs while the infant is sleeping. Also known as crib death.

transition The end of the first stage of labor, when the cervix is fully dilated.

very-low-birth-weight infants Infants who weigh less than 3.3 pounds (1,500 grams) at birth.

mos82599_04_c04_101-134.indd 134 2/11/16 8:20 AM