Oh, Baby! Prenatal and Newborn Development

CHAPTER 4 BIRTH AND THE NEWBORN BABY

Welcome

Debjyoti Sakar, 12 years, India

Relatives approach a mother and her newborn to welcome the baby into the family. In Chapter 4, we explore the birth process, the marvelous competencies of the newborn, and the challenges of new parenthood.

Reprinted with permission from The International Museum of Children’s Art, Oslo, Norway

WHAT’S AHEAD IN CHAPTER 4

4.1 The Stages of Childbirth

Stage 1: Dilation and Effacement of the Cervix • Stage 2: Delivery of the Baby • Stage 3: Birth of the Placenta • The Baby’s Adaptation to Labor and Delivery • The Newborn Baby’s Appearance • Assessing the Newborn’s Physical Condition: The Apgar Scale

4.2 Approaches to Childbirth

Natural, or Prepared, Childbirth • Home Delivery

4.3 Medical Interventions

Fetal Monitoring • Labor and Delivery Medication • Instrument Delivery • Cesarean Delivery

4.4 Birth Complications

Oxygen Deprivation • Preterm and Low-Birth-Weight Infants • Birth Complications, Parenting, and Resilience

■Cultural Influences: A Cross-National Perspective on Health Care and Other Policies for Parents and Newborn Babies

4.5 The Newborn Baby’s Capacities

Reflexes • States • Sensory Capacities • Neonatal Behavioral Assessment

■Social Issues: Health: The Mysterious Tragedy of Sudden Infant Death Syndrome

4.6 The Transition to Parenthood

Early Parent–Infant Contact • Changes in the Family System • Single-Mother Families • Parent Interventions

■Biology and Environment: Parental Depression and Child Development

Although Yolanda and Jay completed my child development course three months before their baby was born, both agreed to return to share their reactions to birth and new parenthood with next term’s class. Two-week-old Joshua came along as well. Yolanda and Jay’s story revealed that the birth of a baby is one of the most dramatic and emotional events in human experience. Jay was present throughout Yolanda’s labor and delivery. Yolanda explained:

By morning, we knew I was in labor. It was Thursday, so we went in for my usual weekly appointment. The doctor said, yes, the baby was on the way, but it would be a while. He told us to go home and relax and come to the hospital in three or four hours. We checked in at 3 in the afternoon; Joshua arrived at 2 o’clock the next morning. When, finally, I was ready to deliver, it went quickly. A half hour or so and some good hard pushes, and there he was! His face was red and puffy, and his head was misshapen, but I thought, “Our son! I can’t believe he’s really here.”

Jay was also elated by Joshua’s birth. “I wanted to support Yolanda and to experience as much as I could. It was awesome, indescribable,” he said, holding little Joshua over his shoulder and patting and kissing him gently.

In this chapter, we explore the experience of childbirth, from both the parents’ and the baby’s point of view. Today, women in industrialized nations have many choices about where and how they give birth, and hospitals go to great lengths to make the arrival of a new baby a rewarding, family-centered event.

Joshua reaped the benefits of Yolanda and Jay’s careful attention to his needs during pregnancy. He was strong, alert, and healthy at birth. Nevertheless, the birth process does not always go smoothly. We will consider the pros and cons of medical interventions, such as pain-relieving drugs and surgical deliveries, designed to ease a difficult birth and protect the health of mother and baby. Our discussion also addresses birth complications, paying special attention to infants who experience oxygen deprivation or who are born underweight or too early.

Finally, Yolanda and Jay spoke candidly about how their lives had changed since Joshua’s arrival. “It’s exciting and wonderful,” reflected Yolanda, “but the adjustments are enormous. I wasn’t quite prepared for the intensity of Joshua’s 24-hour-a-day demands.” In the concluding sections of this chapter, we look closely at the remarkable capacities of newborns to adapt to the external world and to communicate their needs. We also consider how parents adjust to the realities of everyday life with a new baby. ■

4.1 THE STAGES OF CHILDBIRTH

4.1 Describe the three stages of childbirth, the baby’s adaptation to labor and delivery, and the newborn baby’s appearance.

It is not surprising that childbirth is often referred to as labor. It is the hardest physical work a woman may ever do. A complex series of hormonal changes initiates the process. As pregnancy advances, the placenta releases increasing amounts of corticotropin-releasing hormone (CRH), a hormone involved in the stress response. High levels of CRH trigger additional placental hormone adjustments that induce uterine contractions. And as CRH rises in the fetal bloodstream in the final prenatal weeks, it stimulates fetal production of the stress hormone cortisol, which promotes development of the lungs in preparation for breathing (Li et al., 2014; Vannuccini et al., 2016). An abnormal increase in maternal CRH in the second or third trimesters of pregnancy may be an important, early predictor of premature birth (Latendresse & Ruiz, 2011; Ruiz et al., 2015).

Several signs let Yolanda know that labor was near:

She occasionally felt the upper part of her uterus contract. These contractions are often called false labor or prelabor because they remain brief and unpredictable for several weeks.

About two weeks before birth, she experienced an event called lightening: Joshua’s head dropped low into her uterus. Placental hormone changes had caused her cervix to soften, and it no longer supported Joshua’s weight so easily.

When she experienced the bloody show, Yolanda knew that labor was only hours or days away. As the cervix began to open, the plug of mucus that sealed it during pregnancy was released, producing a reddish discharge. Soon after, uterine contractions became more frequent, and mother and baby entered the first of three stages of childbirth (see Figure 4.1).

Figure 4.1 The three stages of childbirth.

4.1.1 Stage 1: Dilation and Effacement of the Cervix

Stage 1 is the longest, lasting an average of 12 to 14 hours with a first birth and 4 to 6 hours with later births. Dilation and effacement of the cervix take place: As uterine contractions gradually become more frequent and powerful, they cause the cervix to open (dilate) and thin (efface), forming a clear channel from the uterus into the birth canal, or vagina. The uterine contractions that open the cervix are forceful and regular, starting at 10 to 20 minutes apart and lasting about 15 to 20 seconds each. Gradually, they get closer together, occurring every 2 to 3 minutes, and become stronger, persisting for as long as 60 seconds each.

During this stage, Yolanda could do nothing to speed up the process. Jay held her hand, provided sips of juice and water, and helped her get comfortable. Throughout the first few hours, Yolanda walked, stood, or sat upright. As the contractions became more intense, she leaned against pillows or lay on her side.

The climax of Stage 1 is a brief phase called transition, in which the frequency and strength of contractions are at their peak and the cervix opens completely. Although transition is the most uncomfortable part of childbirth, it is especially important that the mother relax. If she tenses or bears down with her muscles before the cervix is completely dilated and effaced, she may bruise the cervix and slow the progress of labor.

4.1.2 Stage 2: Delivery of the Baby

In Stage 2, which lasts about 50 minutes for a first birth and 20 minutes in later births, the infant is born. Strong contractions of the uterus continue, but the mother also feels a natural urge to squeeze and push with her abdominal muscles. As she does so with each contraction, she forces the baby down and out.

Between contractions, Yolanda dozed lightly. When the doctor announced that the baby’s head was crowning—the vaginal opening had stretched around the entire head—Yolanda felt renewed energy. She knew that soon the baby would arrive. Quickly, with several more pushes, Joshua’s forehead, nose, and chin emerged, then his upper body and trunk. The doctor held him up, wet with amniotic fluid and still attached to the umbilical cord. As air rushed into his lungs, Joshua cried. When the umbilical cord stopped pulsing, it was clamped and cut. A nurse placed Joshua on Yolanda’s chest, where she and Jay could see, touch, and gently talk to him. Then the nurse wrapped Joshua snugly to help with temperature regulation.

4.1.3 Stage 3: Birth of the Placenta

Stage 3 brings labor to an end. A few final contractions and pushes cause the placenta to separate from the wall of the uterus and be delivered in about 5 to 10 minutes. Yolanda and Jay were surprised at the large size of the thick 1½-pound red-gray organ, which had taken care of Joshua’s basic needs for the previous nine months.

4.1.4 The Baby’s Adaptation to Labor and Delivery

At first glance, labor and delivery seem like a dangerous ordeal for the baby. The strong contractions of Yolanda’s uterus exposed Joshua’s head to a great deal of pressure, and they squeezed the placenta and the umbilical cord repeatedly, temporarily reducing Joshua’s supply of oxygen.

Fortunately, healthy babies are equipped to withstand these traumas. The force of the contractions intensifies the baby’s production of stress hormones. Unlike during pregnancy, when excessive stress endangers the fetus (see Chapter 3), during childbirth high levels of infant cortisol and other stress hormones are adaptive. They help the baby withstand oxygen deprivation by sending a rich supply of blood to the brain and heart (Gluckman, Sizonenko, & Bassett, 1999). In addition, stress hormones prepare the baby to breathe by causing the lungs to absorb any remaining fluid and by expanding the bronchial tubes (passages leading to the lungs). Finally, stress hormones arouse the infant into alertness. Joshua was born wide-awake, ready to interact with the surrounding world.

4.1.5 The Newborn Baby’s Appearance

Parents are often surprised at the odd-looking newborn—a far cry from the storybook image they may have had in their minds. The average newborn is 20 inches long and 7½ pounds in weight; boys tend to be slightly longer and heavier than girls. The head is large in comparison to the trunk and legs, which are short and bowed. Proportionally, if your head were as large as that of a newborn infant, you would be balancing something about the size of a watermelon between your shoulders! This combination of a large head (with its well-developed brain) and a small body means that human infants learn quickly in the first few months of life. But unlike most other mammals, they cannot get around on their own until much later.

To accommodate the well-developed brain, a newborn’s head is large in relation to the trunk and legs. Notice the vernix on the baby’s skin, which protected it from chapping while exposed to the amniotic fluid during pregnancy.

Noctiluxx/Getty Images

Even though newborn babies may not match parents’ idealized image, some features do make them attractive. Their captivating round faces, chubby cheeks, large foreheads, and big eyes generally make adults want to pick them up and cuddle them (Luo et al., 2015).

4.1.6 Assessing the Newborn’s Physical Condition: The Apgar Scale

To assess the newborn’s physical condition quickly, doctors and nurses use the Apgar Scale. As Table 4.1 shows, a rating of 0, 1, or 2 on each of five characteristics is made at 1 minute and again at 5 minutes after birth. A combined Apgar score of 7 or better indicates that the infant is in good physical condition. If the score is between 4 and 6, the baby requires assistance in establishing breathing and other vital signs. If the score is 3 or below, the infant is in serious danger and requires emergency medical attention (Apgar, 1953). Two Apgar ratings are given because some babies have trouble adjusting at first but do quite well after a few minutes.

Table 4.1 The Apgar Scale

Rating

Signa

0

1

2

Color (Appearance)b

Blue body, arms, and legs

Body pink with blue arms and legs

Body, arms, and legs completely pink

Heart rate (Pulse)

No heartbeat

Under 100 beats per minute

100 to 140 beats per minute

Reflex irritability (Grimacing, sneezing, and coughing)

No response

Weak reflexive response

Strong reflexive response

Muscle tone (Activity)

Completely limp

Weak movements of arms and legs

Strong movements of arms and legs

Breathing (Respiratory effort)

No breathing for 60 seconds

Irregular, shallow breathing

Strong breathing and crying

aAs an aid for remembering these signs, note that the boldfaced first letter of the words in parentheses—Appearance, Pulse, Grimacing, Activity, and Respiratory effort—together spell Apgar.

bIt is difficult to apply the pink color criterion to babies with olive to brown skin tones. However, all newborns can be rated for the pinkish glow that results from the flow of oxygen through body tissues.

Source: Apgar, 1953.

Ask Yourself

Connect ■ Contrast the positive impact of the baby’s production of high levels of stress hormones during childbirth with the negative impact of severe maternal stress on the fetus, discussed on pages 108–109 in Chapter 3.

Apply ■ On seeing her newborn baby for the first time, Caroline exclaimed, “Why is she so out of proportion?” What observations prompted Caroline to ask this question? Explain why her baby’s appearance is adaptive.

4.2 APPROACHES TO CHILDBIRTH

4.2 Describe natural childbirth and home delivery, noting benefits and concerns associated with each.

Childbirth practices, like other aspects of family life, are molded by the society of which mother and baby are a part. In many village and tribal cultures, expectant mothers are well-acquainted with the childbirth process. For example, the Jarara of South America and the Pukapukans of the Pacific Islands treat birth as a vital part of daily life (Lowis & McCaffery, 2004). The Jarara mother gives birth in full view of the entire community, including small children. The Pukapukan girl is so familiar with the events of labor and delivery that she can frequently be seen playing at it. Using a coconut to represent the baby, she stuffs it inside her dress, imitates the mother’s pushing, and lets the nut fall at the proper moment.

In most nonindustrialized cultures, women are assisted—though often not by medical personnel—during labor and delivery. Among the Mende of Sierra Leone, birth attendants are appointed by the village chief and are highly respected members of their communities. They visit expectant mothers before and after a birth to provide advice, can be called to help deliver a baby at any time, and practice traditional strategies to promote delivery, including massaging the abdomen and supporting the woman in a squatting position (Dorwie & Pacquiao, 2014). In Bolivia, a Siriono mother delivers her own baby in a hammock with a crowd of women close by, who keep her company. The father cuts the umbilical cord and joins the mother in tending to the newborn for the first few days (Reed, 2005).

In Western nations, childbirth has changed dramatically over the centuries. Before the late 1800s, birth usually took place at home and was a family-centered event. The industrial revolution brought greater crowding to cities, along with new health problems. As a result, childbirth moved from home to hospital, where the health of mothers and babies could be protected (Borst, 1995). Once doctors assumed responsibility for childbirth, women’s knowledge of it declined, and relatives and friends no longer participated.

By the 1950s and 1960s, women had begun to question the medical procedures that had come to be used during labor and delivery. Many felt that routine use of strong drugs and delivery instruments had robbed them of a precious experience and was often neither necessary nor safe for the baby. Gradually, a natural childbirth movement arose in Europe and spread to North America. Its purpose was to make hospital birth as comfortable and rewarding for mothers as possible. Today, most hospitals offer birth centers that are family-centered and homelike and that encourage early contact between parents and baby.

In Sierra Leone, a new mother rests comfortably after giving birth to twins. She had her first twin at home, assisted by village birth attendants. After complications arose, the birth attendants took her to a clinic, where they collaborated with nurses in delivering her second twin. Throughout, cultural practices remained a part of this birth experience.

© MICHAEL G. SEAMANS/PULITZER CENTER ON CRISIS REPORTING

Freestanding birth centers also exist. They permit greater maternal control over labor and delivery, including choice of delivery positions and presence of family members and friends, as well as timely transfer to a hospital should an emergency arise. And a small number of North American women reject institutional birth entirely and choose to have their babies at home.

4.2.1 Natural, or Prepared, Childbirth

Yolanda and Jay chose natural, or prepared, childbirth—a group of techniques aimed at reducing pain and medical intervention and making childbirth a rewarding experience. Most natural childbirth programs draw on methods developed by Grantly Dick-Read (1959) in England and Fernand Lamaze (1958) in France. These physicians recognized that cultural attitudes had taught women to fear the birth experience. An anxious, frightened woman in labor tenses her muscles, heightening the pain that usually accompanies strong contractions.

As the father looks on, a mother reaches for her newborn after giving birth. A companion’s support is a vital part of natural childbirth, which is associated with shorter labors, fewer complications, and a more rewarding birth experience.

Burger/Phanie/Alamy Stock Photo

In a typical natural childbirth program, the expectant mother and a companion (a partner, relative, or friend) participate in three activities:

Classes. Yolanda and Jay attended a series of classes in which they learned about the anatomy and physiology of labor and delivery. Knowledge about the birth process reduces a mother’s fear.

Relaxation and breathing techniques. During each class, Yolanda was taught relaxation and breathing exercises aimed at counteracting the pain of uterine contractions.

Labor coach. Jay learned how to help Yolanda during childbirth by reminding her to relax and breathe, massaging her back, supporting her body, and offering encouragement and affection.

Social Support and Natural Childbirth

Social support is important to the success of natural childbirth. Mothers who are supported during labor and delivery—either by a doula (a Greek word referring to a trained lay attendant) or by a relative or friend with doula training—less often have instrument-assisted or cesarean (surgical) deliveries or need medication to control pain. Also, their babies’ Apgar scores are higher, and they are more likely to be breastfeeding at a two-month follow-up (Campbell et al., 2006, 2007; Hodnett et al., 2012; McGrath & Kennell, 2008).

The continuous rather than intermittent support of a doula during labor and delivery strengthens these benefits for mothers and babies—outcomes evident in studies conducted in both developing and developed nations and among women of diverse ethnicities (Hodnett et al., 2012). Furthermore, this aspect of natural childbirth makes Western hospital-birth customs more acceptable to women from parts of the world where assistance from family and community members is the norm (Dundek, 2006).

Look and Listen

Talk to several mothers about social supports available to them during labor and delivery. From the mothers’ perspectives, how did those supports (or lack of support) affect the birth experience?

Positions for Delivery

When natural childbirth is combined with delivery in a birth center or at home, mothers often give birth in an upright, sitting position rather than lying flat on their backs with their feet in stirrups (the traditional hospital delivery room practice). When mothers are upright, labor is slightly shorter because contractions are stronger and pushing is more effective (Kopas, 2014). The baby benefits from a richer supply of oxygen because blood flow to the placenta is increased, and fewer infant heartbeat irregularities occur. Compared with those who give birth lying on their backs, women who choose an upright position are less likely to use pain-relieving medication or to have instrument-assisted deliveries (Gupta, Hofmeyr, & Shehmar, 2012; Romano & Lothian, 2008).

In another increasingly popular method, water birth, the mother sits in a warm tub of water, which supports her weight, relaxes her, and provides her with the freedom to move into any position she finds most comfortable. Among mothers at low risk for birth complications, water birth is associated with reduced maternal stress, shorter labor, and greater likelihood of medication-free delivery than both back-lying and seated positions. As long as water birth is carefully managed by skilled health professionals, it poses no additional risk of infection or safety to mothers or babies (American Association of Birth Centers, 2014; Vanderlaan, Hall, & Lewitt, 2018).

4.2.2 Home Delivery

Home birth has always been popular in certain industrialized nations, such as England, the Netherlands, and Sweden. The number of American women choosing to have their babies at home rose during the 1970s and 1980s but remains small, at less than 1 percent (Martin et al., 2018). Although some home births are attended by doctors, many more are handled by certified nurse-midwives, who have degrees in nursing and additional training in childbirth management.

The joys and perils of home delivery are well illustrated by a story told by Don, a father of four. “Our first child was delivered in the hospital,” he said. “Even though I was present, Kathy and I found the atmosphere to be rigid and insensitive. We wanted a warmer, more personal birth environment.” With a nurse-midwife’s coaching, Don delivered their second child, Cindy, at their rural farmhouse. Three years later, when Kathy went into labor with Marnie, a heavy snowstorm prevented the midwife from reaching the house on time, so Don delivered the baby alone. The birth was difficult, and Marnie failed to breathe for several minutes. With great effort, Don revived her. The frightening memory of Marnie’s limp, blue body convinced Don and Kathy to return to the hospital to have their last child. By then, the hospital’s birth practices had changed, and the event was a rewarding one for both parents.

After a home birth, the midwife and a lay attendant provide support to the new mother. For healthy women attended by a well-trained doctor or midwife, home birth is as safe as hospital birth.

© ANDERSEN ROSS/GETTY IMAGES

Don and Kathy’s experience raises the question: Is it just as safe to give birth at home as in a hospital? For healthy women who are assisted by a well-trained doctor or midwife, it seems so because complications rarely occur (Cheyney et al., 2014). However, if attendants are not carefully trained and prepared to handle emergencies, the likelihood of infant disability and death is high (Grünebaum et al., 2015). When mothers are at risk for any kind of complication, the appropriate place for labor and delivery is the hospital, where life-saving treatment is available.

4.3 MEDICAL INTERVENTIONS

4.3 List common medical interventions during childbirth, circumstances that justify their use, and any dangers associated with each.

Medical interventions during childbirth occur in both industrialized and nonindustrialized cultures. For example, some tribal and village societies have discovered foods, oils, and herbs that stimulate labor and have devised surgical techniques to deliver babies (Alliance of African Midwives, 2012; Jordan, 1993). Yet childbirth in North America, more so than elsewhere in the world, is a medically monitored and controlled event. Use of some medical procedures has reached epic proportions—in part because of rising rates of multiple births and other high-risk deliveries, which are associated with increased maternal age and use of fertility treatments. But births unaffected by these factors are also medicalized.

What medical techniques are doctors likely to use during labor and delivery? When are they justified, and what dangers do they pose to mothers and babies?

4.3.1 Fetal Monitoring

Fetal monitors are electronic instruments that track the baby’s heart rate during labor. An abnormal heartbeat pattern may indicate that the baby is in distress due to anoxia, or inadequate oxygen supply, and needs to be delivered immediately. Continuous fetal monitoring, which is required in most U.S. hospitals, is used in over 85 percent of U.S. births. The most popular type of monitor is strapped across the mother’s abdomen throughout labor. A second, more accurate method involves threading a recording device through the cervix and placing it directly under the baby’s scalp.

Fetal monitoring is a safe medical procedure that has saved the lives of many babies in high-risk situations. In healthy pregnancies, however, it does not reduce the already low rates of infant brain damage and death. Furthermore, most infants have some heartbeat irregularities during labor, so critics worry that fetal monitors identify many babies as in danger who, in fact, are not. Monitoring is linked to an increase in the number of instrument and cesarean (surgical) deliveries, practices we will discuss shortly (Mullins, Lees, & Brocklehurst, 2017). In addition, some women complain that the devices are uncomfortable and interfere with the normal course of labor.

Still, fetal monitors will probably continue to be used routinely in the United States, even though they are not necessary in most cases. Doctors fear that they will be sued for malpractice if they cannot show that they did everything they could to avert the death of an infant or the birth of an infant with problems.

The fetal monitor strapped across this mother’s abdomen uses ultrasound to record fetal heart rate throughout labor. In high-risk situations, fetal monitoring saves many lives. But it also may encourage unnecessary instrument and cesarean deliveries.

© BSIP SA/ALAMY Stock Photo

4.3.2 Labor and Delivery Medication

Some form of medication is used in over 60 percent of U.S. births (Declercq et al., 2014). Analgesics, drugs used to relieve pain, may be given in mild doses during labor to help a mother relax. Anesthetics are a stronger type of painkiller that blocks sensation. Currently, the most common approach to controlling pain during labor is epidural analgesia, in which a regional pain-relieving drug is delivered continuously through a catheter into a small space in the lower spine. Unlike older spinal block procedures, which numb the entire lower half of the body, epidural analgesia limits pain reduction to the pelvic region. Because the mother retains the capacity to feel the pressure of the contractions and to move her trunk and legs, she is able to push during the second stage of labor.

Although pain-relieving drugs help women cope with childbirth and enable doctors to perform essential medical interventions, they also can cause problems. Epidural analgesia, for example, weakens uterine contractions. As a result, labor is prolonged, and the chances of instrument delivery or cesarean (surgical) birth increase. And because drugs rapidly cross the placenta, exposed newborns are at risk for respiratory distress (Kumar et al., 2014). They also tend to have lower Apgar scores, to be sleepy and withdrawn, to suck poorly during feedings, and to be irritable when awake (Platt, 2014; Törnell et al., 2015). Although no confirmed long-term consequences for development exist, the negative impact of these drugs on the newborn’s adjustment supports the current trend to limit their use.

4.3.3 Instrument Delivery

Forceps, metal clamps placed around the baby’s head to pull the infant from the birth canal, have been used since the sixteenth century to speed up delivery (see Figure 4.2). A more recent instrument, the vacuum extractor, consists of a plastic cup (placed on the baby’s head) attached to a suction tube. Instrument delivery is appropriate if the mother’s pushing during the second stage of labor does not move the baby through the birth canal in a reasonable period of time.

Instrument use has declined considerably over the past three decades, partly because doctors more often deliver babies surgically when labor problems arise. Today, forceps and (more often) vacuum extractors continue to be used in about 3 percent of U.S. births (Martin et al., 2018).

Using forceps to pull the baby through most or all of the birth canal greatly increases the risk of brain damage. As a result, forceps are seldom used this way today. Low-forceps delivery (carried out when the baby is most of the way through the vagina) is associated with injury to the baby’s head and the mother’s tissues. Vacuum extractors, which have rapidly replaced forceps as the dominant instrument, are less likely to tear the mother’s tissues. Nevertheless, cup suction doubles the risk of bleeding beneath the baby’s skin and on the outside of the skull compared with nonassisted deliveries. And the risk of more serious complications, including bleeding beneath the skull and seizures (which can damage the brain), increases tenfold (Ekéus, Högberg, & Norman, 2014; Muraca et al., 2017). Consequently, neither instrument should be used when mothers can be encouraged to deliver normally and there is no special reason to hurry the birth.

4.3.4 Cesarean Delivery

A cesarean delivery is a surgical birth; the doctor makes an incision in the mother’s abdomen and lifts the baby out of the uterus. Forty years ago, cesarean delivery was rare. Since then, cesarean rates have climbed internationally, reaching 16 percent in Finland, 24 percent in New Zealand, 26 percent in Canada, 32 percent in Australia and Switzerland, and 37 percent in the United States (Martin et al., 2018; OECD, 2017c).

Cesareans have always been warranted by medical emergencies, such as Rh incompatibility, premature separation of the placenta from the uterus, or serious maternal illness or infection (for example, the herpes simplex 2 virus, which can infect the baby during a vaginal delivery). Cesareans are also justified when babies are in breech position, turned so that the buttocks or feet would be delivered first (about 1 in every 25 births). The breech position increases the chances of squeezing of the umbilical cord as the large head moves through the birth canal, thereby depriving the infant of oxygen. Head injuries are also more likely. But the infant’s exact position makes a difference. Certain breech babies fare just as well with a normal delivery as with a cesarean (Vistad et al., 2013). Sometimes the doctor can gently turn the baby into a head-down position during the early part of labor.

Figure 4.2 Instrument delivery. The pressure that must be applied to pull the infant from the birth canal with forceps can injure the baby’s head. An alternative method, the vacuum extractor, is less likely than forceps to injure the mother’s tissues. Nevertheless, risk of infant scalp injuries and internal bleeding in the eyes and skull remains.

Although previously doctors used the rule, “Once a cesarean, always a cesarean,” today many women are offered the option of a trial of labor in subsequent births, and most who attempt a vaginal birth are successful (ACOG, 2017). The recent practice of repeated cesareans, however, cannot account for the rise in cesarean deliveries in Western nations. Instead, medical control over childbirth is largely responsible. Because many needless cesareans are performed, pregnant women should ask questions about the procedure when choosing a doctor. Although the operation itself is safe, mother and baby require more time for recovery. Anesthetic may have crossed the placenta, making cesarean newborns sleepy and unresponsive and putting them at increased risk for breathing difficulties (Kotecha, Gallacher, & Kotecha, 2016; Ramachandrappa & Jain, 2008).

Ask Yourself

Connect ■ How might natural childbirth positively affect the parent–newborn relationship? Explain how your answer illustrates bidirectional influences between parent and child, emphasized in ecological systems theory.

Apply ■ Sharon, a heavy smoker, has just arrived at the hospital in labor. Which one of the medical interventions discussed in the preceding sections is her doctor justified in using? (For help in answering this question, review the prenatal effects of tobacco on pages 100–101 in Chapter 3.

Reflect ■ If you were an expectant parent, would you choose home birth? Why or why not?

4.4 BIRTH COMPLICATIONS

4.4a Describe risks associated with oxygen deprivation and with preterm and low-birth-weight infants, along with effective interventions.

4.4b Describe factors that promote resilience in infants who survive a traumatic birth.

We have seen that some infants—in particular, those whose mothers are in poor health, do not receive good medical care, or have a history of pregnancy problems—are especially likely to experience birth complications. Inadequate oxygen, a pregnancy that ends too early, and a baby who is born underweight are serious risks to development that we have touched on many times. A baby remaining in the uterus too long is yet another risk. Let’s look at the impact of each complication on later development.

4.4.1 Oxygen Deprivation

Some years ago, I got to know 4-year-old Melinda and her mother, Judy, both of whom participated in a special program for children with disabilities at our laboratory school. Melinda has cerebral palsy, a general term for a variety of impairments in muscle coordination caused by brain damage before, during, or just after birth. The disorder can range from very mild tremors to severe crippling and intellectual disability. One out of every 500 American children has cerebral palsy. About 10 percent experienced anoxia as a result of decreased maternal blood supply during labor and delivery (Clark, Ghulmiyyah, & Hankins, 2008; McIntyre et al., 2013).

Melinda walks with a halting, lumbering gait and has difficulty keeping her balance. “Some mothers don’t know how the palsy happened,” confided Judy, “but I do. I got pregnant accidentally, and my boyfriend didn’t want to have anything to do with it. I was frightened and alone most of the time. I arrived at the hospital at the last minute. Melinda was breech, and the cord was wrapped around her neck.”

Squeezing of the umbilical cord, as in Melinda’s case, is one cause of anoxia. Another cause is placenta abruptio, or premature separation of the placenta, a life-threatening event with a high rate of infant death. Factors related to it include multiple fetuses and teratogens that cause constriction of blood vessels and abnormal development of the placenta, such as tobacco, alcohol, and cocaine (Downes, Shenassa, & Grantz, 2017). Just as serious is placenta previa, a condition caused by implantation of the blastocyst so low in the uterus that the placenta covers the cervical opening. As the cervix dilates and effaces in the third trimester, part of the placenta may detach. Women who have had previous cesareans or who are carrying multiple fetuses are at increased risk (Trønnes et al., 2014). Although placenta abruptio and placenta previa occur in only 1 to 2 percent of births, they can cause severe hemorrhaging, which requires that an emergency cesarean be performed.

Treatment for this newborn, who experienced oxygen deprivation, includes a cooling water blanket to lower the baby’s body temperature, which helps prevent brain damage.

© Andrew Shurtleff/The Daily Progress/AP Images

In still other instances, the birth seems to go along all right, but the baby fails to start breathing within a few minutes. Healthy newborns can survive periods of little or no oxygen longer than adults can; they reduce their metabolic rate, thereby conserving the limited oxygen available. Nevertheless, brain damage is likely if regular breathing is delayed more than 10 minutes (Rennie & Rosenbloom, 2011). Can you think of other possible causes of oxygen deprivation that you learned about as you studied prenatal development and birth?

After initial brain injury from anoxia during labor or delivery, another phase of cell death can occur several hours later and last for several days or longer. Hypothermia treatment, by placing anoxic newborns in a head-cooling device shortly after birth for 72 hours, substantially reduces this secondary brain damage (detected through brain scans) (Hoehn et al., 2008). Another alternative—whole-body cooling in which anoxic newborns are laid on a precooled water blanket—leads to an impressive reduction in death and disability rates during the first two years (Allen, 2014).

Still, nearly half of newborns treated with hypothermia display persisting motor and cognitive deficits. Those who experienced mild to moderate anoxia often improve over time (Azzopardi et al., 2016; Pappas & Korzeniewski, 2016). In Melinda’s case, her physical disability was permanent, but with warm, stimulating intervention services, she was just slightly behind in cognitive and language skills as a preschooler. When development is severely impaired, the anoxia was likely extreme. Perhaps it was caused by prenatal insult to the respiratory system, or it may have happened because the newborn’s lungs were not yet mature enough to breathe.

For example, infants born more than six weeks early commonly have respiratory distress syndrome (otherwise known as hyaline membrane disease). Their tiny lungs are so poorly developed that the air sacs collapse, causing serious breathing difficulties. Although mechanical respirators keep many such infants alive, some suffer permanent brain damage from lack of oxygen, and in other cases their delicate lungs are harmed by the treatment itself. As we will see next, respiratory distress syndrome is just one of many risks for babies born too soon.

4.4.2 Preterm and Low-Birth-Weight Infants

Janet, nearly six months pregnant, and her husband, Rick, boarded a flight in Hartford, Connecticut, on their way to a vacation in Hawaii. During a stopover in San Francisco, Janet told Rick she was bleeding. Rushed to a hospital, she gave birth to Keith, who weighed less than 1½ pounds. Delivered 23 weeks after conception, he had barely reached the age of viability (see page 95 in Chapter 3).

During Keith’s first month, he experienced one crisis after another. Three days after birth, an ultrasound suggested that fragile blood vessels feeding Keith’s brain had hemorrhaged, a complication that can cause brain damage. Within three weeks, Keith had surgery to close a heart valve that seals automatically in full-term babies. Keith’s immature immune system made infections difficult to contain. Repeated illnesses and the drugs used to treat them caused permanent hearing loss. Keith also had respiratory distress syndrome and breathed with the help of a respirator. Soon evidence of lung damage emerged. More than three months of hospitalization passed before Keith’s rough course of complications and treatment eased.

Babies born three weeks or more before the end of a full 38-week pregnancy or who weigh less than 5½ pounds (2,500 grams) have for many years been referred to as “premature.” Birth weight is the best available predictor of infant survival and healthy development. Many newborns who weigh less than 3½ pounds (1,500 grams) experience persisting difficulties, an effect that becomes stronger as length of pregnancy and birth weight decrease (see Figure 4.3) (Bolisetty et al., 2006; Wilson-Ching et al., 2013). Brain abnormalities, frequent illness, inattention, overactivity, sensory impairments, poor motor coordination, language delays, low intelligence test scores, deficits in school learning, and emotional and behavior difficulties are some of the problems that persist through childhood and adolescence and into adulthood (Breeman et al., 2017; Lemola, 2015; Mathewson et al., 2017).

About 11 percent of American infants are born early, and 8 percent are born underweight. The two risk factors often co-occur, and they can strike unexpectedly, as Keith’s case illustrates. But the problem is highest among poverty-stricken women (Martin et al., 2018). These mothers, as indicated in Chapter 3, are more likely to be under stress, undernourished, and exposed to other harmful environmental influences—factors strongly linked to low birth weight. In addition, they often do not receive adequate prenatal care.

Figure 4.3 Rates of infant survival and child disabilities by length of pregnancy. In a follow-up of more than 2,300 babies born between 23 and 28 weeks gestation, the percentage who survived decreased and the percentage who displayed moderate to severe disabilities (assessed during the preschool years) increased with reduced length of pregnancy. Severe disabilities included cerebral palsy (unlikely to ever walk), severely delayed mental development, deafness, and blindness. Moderate disabilities included cerebral palsy (able to walk with assistance), moderately delayed mental development, and hearing impairments partially correctable with a hearing aid. (Adapted from Bolisetty et al., 2006.)

African-American infants are especially vulnerable to early and underweight birth: They have about twice the rates of white and Hispanic infants, even after accounting for SES and other potentially contributing factors, such as single parenthood and young maternal age (Martin et al., 2018). Researchers suspect that African-American expectant mothers’ greater exposure to multiple chronic stressors, such as job strain (long hours at tiring work), crime-ridden neighborhoods, crowded living conditions, and prejudice and discrimination, is involved (Dunkel-Shetter, 2011; Dunkel-Shetter & Lobel, 2012). Many studies confirm, for example, that African-American women’s experience of race-related stressors—biased treatment at school, at work, or in access to housing—predict lower birth weight in their infants (Black, Johnson, & VanHoose, 2015).

Furthermore, low birth weight is often transmitted across generations: Women who were underweight at birth themselves are nearly twice as likely as other women to bear an underweight baby (Collins, Rankin, & David, 2011; Ncube et al., 2017). The possible causes are diverse: They may be genetic, environmental, or epigenetic—for example, excessive prenatal stress may impair offspring’s lifelong capacity to manage stress (see page 109 in Chapter 3). When a daughter becomes pregnant, she exposes her fetus to severe emotional stress and its negative consequences.

Recall from Chapter 2 that prematurity is also common in multiple births. About 55 percent of twins and more than 90 percent of triplets are born early and low birth weight (Martin et al., 2018). Because space inside the uterus is restricted, multiples gain less weight than singletons in the second half of pregnancy.

Preterm Versus Small-for-Date Infants

Although preterm and low-birth-weight infants face many obstacles to healthy development, most go on to lead normal lives; about half of those born at 23 to 24 weeks gestation and weighing only a couple of pounds at birth have no disability (refer again to Figure 4.3). To better understand why some babies do better than others, researchers divide them into two groups. Preterm infants are born several weeks or more before their due date. Although they are small, their weight may still be appropriate, based on time spent in the uterus. Small-for-date infants are below their expected weight considering the length of the pregnancy. Some small-for-date infants are actually full-term. Others are preterm babies who are especially underweight.

Small-for-date infants, especially those who are also preterm, usually have more serious problems. During the first year, they are more likely to die, catch infections, and show evidence of brain damage. By middle childhood, they are smaller in stature, have lower intelligence test scores, are less attentive, achieve more poorly in school, and are socially immature (Katz et al., 2013; Tsai et al., 2015; Wilson-Ching et al., 2013).

Small-for-date infants probably experienced inadequate nutrition before birth. Perhaps their mothers did not eat properly, the placenta did not function normally, or the babies themselves had defects that prevented them from growing as they should. In some of these babies, an abnormally functioning placenta permitted ready transfer of stress hormones from mother to fetus. Consequently, small-for-date infants are especially likely to suffer from neurological impairments that permanently weaken their capacity to manage stress (Osterholm, Hostinar, & Gunnar, 2012). Severe stress, in turn, heightens their susceptibility to later physical and psychological health problems.

Even among preterm newborns whose weight is appropriate for length of pregnancy, just 7 to 14 more days—from 34 to 35 or 36 weeks—greatly reduces rates of illness, costly medical procedures, and lengthy hospital stays (although they need greater medical intervention than full-term babies) (Ananth, Friedman, & Gyamfi-Bannerman, 2013). In longitudinal follow-ups of thousands of births, infants born even 1 or 2 weeks early showed slightly lower kindergarten cognitive and language scores and third-grade reading and math scores than agemates who experienced a full-length prenatal period (Noble et al., 2012; Woythaler et al., 2015). These outcomes persisted even after controlling for other factors linked to achievement, such as birth weight and SES. Yet doctors often induce births several weeks preterm, under the misconception that these babies are developmentally “mature.”

Consequences for Caregiving

Imagine a scrawny, thin-skinned infant only a little larger than the size of your hand. You try to play with the baby by stroking and talking softly, but he is sleepy and unresponsive. When you feed him, he sucks poorly. During the short, unpredictable periods in which he is awake, he is usually irritable.

The appearance and behavior of preterm infants—scrawny and thin-skinned, sleepy and unresponsive, irritable when briefly awake—can lead parents to be less sensitive in caring for them. Compared with full-term infants, preterm babies—especially those who are very ill at birth—are less often held close, touched, and talked to gently. At times, mothers of these infants resort to interfering pokes and verbal commands in an effort to obtain a higher level of response from them (Feldman, 2007b; Forcada-Guex et al., 2006). This may explain why preterm babies as a group are at risk for child abuse.

Distressed, emotionally reactive preterm infants are particularly susceptible to the effects of parenting quality: Among a sample of preterm 9-month-olds, the combination of infant negativity and angry or intrusive parenting yielded the highest rates of behavior problems at 2 years of age. But with warm, sensitive parenting, distressed preterm babies’ rates of behavior problems were the lowest (Poehlmann et al., 2011).

When preterm infants are born to isolated, poverty-stricken mothers who cannot provide good nutrition, health care, and parenting, the likelihood of unfavorable outcomes increases. In contrast, parents with stable life circumstances and social supports usually can overcome the stresses of caring for a preterm infant (Ment et al., 2003). In these cases, even sick preterm babies have a good chance of catching up in development by middle childhood.

These findings suggest that how well preterm babies develop has a great deal to do with the parent–child relationship. Consequently, interventions directed at supporting both sides of this tie are more likely to help these infants recover.

Interventions for Preterm Infants

A preterm baby is cared for in a special Plexiglas-enclosed bed called an isolette. Temperature is carefully controlled because these infants cannot yet regulate their own body temperature effectively. To help protect the baby from infection, air is filtered before it enters the isolette. When a preterm infant is fed through a stomach tube, breathes with the aid of a respirator, and receives medication through an intravenous needle, the isolette can be very isolating indeed! Physical needs that otherwise would lead to close contact and other human stimulation are met mechanically.

Special Infant Stimulation

In proper doses, certain kinds of stimulation can help preterm infants develop. In some intensive care nurseries, preterm babies can be seen rocking in suspended hammocks, lying on waterbeds designed to replace the gentle motion they would have received while still in the mother’s uterus, or listening to soft music—experiences that promote faster weight gain, improved breathing, more predictable sleep patterns, and greater alertness (Cramer et al., 2018; Marshall-Baker, Lickliter, & Cooper, 1998; Schwilling et al., 2014). In one experiment, extremely preterm newborns, born between the 25th and 32nd prenatal weeks, were exposed either to recordings of their mother’s voice and heartbeat for several hours each day or to routine hospital noise. At age 1 month, an ultrasound revealed that auditory areas of the brain had grown substantially larger in the maternal sounds group (see Figure 4.4) (Webb et al., 2015). Listening to womblike, familiar rhythmic maternal sounds, as opposed to the unpredictable din of hospital equipment, promoted brain development.

Touch is an especially important form of stimulation. In baby animals, touching the skin releases certain brain chemicals that support physical growth—effects believed to occur in humans as well. When preterm infants were gently massaged several times each day in the hospital, they gained weight faster and, at the end of the first year, were more advanced in mental and motor development than preterm babies not given this stimulation (Álvarez et al., 2017; Field, Hernandez-Reif, & Freedman, 2004).

Figure 4.4 Listening to mother’s voice and heartbeat enhances brain development in extremely preterm newborns. Infants born between the 25th and 32nd prenatal weeks were randomly assigned to hear either recordings of their mother’s voice and heartbeat for several hours a day or routine, unpatterned hospital noise. After a month’s exposure in the intensive care nursery, ultrasound measures showed that the left and right cerebral auditory areas were substantially thicker in the maternal sounds group than the hospital noise group. In addition to highlighting an effective intervention, the results suggest that exposure to soft, rhythmic maternal sounds during pregnancy enhances early brain growth. (Based on Webb et al., 2015.)

In developing countries where hospitalization is not always possible, skin-to-skin “kangaroo care” is the most readily available intervention for promoting the survival and development of preterm babies. It involves placing the infant in a vertical position between the mother’s breasts or next to the father’s chest (under the parent’s clothing) so the parent’s body functions as a human incubator. Kangaroo care offers fathers a unique opportunity to increase their involvement in caring for the preterm newborn.

Kangaroo skin-to-skin contact fosters improved oxygenation of the baby’s body, temperature regulation, sleep, breastfeeding, alertness, and infant survival (Conde-Agudelo, Belizan, & Diaz-Rossello, 2011; Kaffashi et al., 2013). In addition, the kangaroo position provides the baby with gentle stimulation of all sensory modalities: hearing (through the parent’s voice), smell (through proximity to the parent’s body), touch (through skin-to-skin contact), and vision (through the upright position). Mothers and fathers practicing kangaroo care feel more confident about caring for their fragile babies, interact more sensitively and affectionately, and feel more attached to them (Dodd, 2005; Feldman, 2007a).

A mother uses skin-to-skin “kangaroo care” to warm and gently stimulate her preterm newborn at a hospital in Manilla, the Philippines. In developing countries, kangaroo care may be the most readily available intervention for promoting the survival of preterm and underweight babies. In Western nations, kangaroo care is often used as a supplement to hospital intensive care.

© PAULA BRONSTEIN/GETTY IMAGES

Together, these factors may explain why preterm babies given many hours of kangaroo care in their early weeks, compared to those given little or no such care, are more likely to explore novel toys and score higher on measures of mental and motor development during the first year and beyond (Bera et al., 2014; Feldman, 2007a). In an investigation that followed children born preterm until age 10, those who had experienced two weeks of kangaroo care after birth, compared with matched controls given standard incubator care, displayed a more adaptive cortisol stress response, better organized sleep, more favorable mother–child interaction, and enhanced cognitive development. Favorable neurobiological and cognitive outcomes persisted through middle childhood (Feldman, Rosenthal, & Eidelman, 2014). Because of its diverse benefits, most hospital nurseries in Western nations offer kangaroo care to parents and preterm newborns.

Training Parents in Infant Caregiving Skills

Interventions that support parents of preterm infants generally teach them how to recognize and respond to the baby’s needs. For parents with the economic and personal resources to care for a preterm infant, just a few sessions of coaching in recognizing and responding to the baby’s needs are linked to enhanced parent–infant interaction, reduced infant crying and improved sleep, more rapid language development in the second year, and steady gains in mental test performance that equal those of full-term children by middle childhood (Achenbach, Howell, & Aoki, 1993; Newnham, Milgrom, & Skouteris, 2009).

When preterm infants live in stressed, economically disadvantaged households, long-term intensive intervention is necessary (Guralnick, 2012). In the Infant Health and Development Program, preterm babies born into poverty received a comprehensive intervention aimed at promoting all aspects of their development. It combined medical follow-up, weekly home visits in which mothers received training in infant care and everyday problem solving, and cognitively stimulating child care from 1 to 3 years of age. More than four times as many intervention children as no-intervention controls (39 versus 9 percent) were within normal range at age 3 in intelligence, psychological adjustment, and physical growth (Bradley et al., 1994). In addition, mothers in the intervention group were more affectionate and more often encouraged play and cognitive mastery in their children—one reason their 3-year-olds may have been developing so favorably (McCarton, 1998).

At ages 5 and 8, children who had attended the child-care program regularly—for more than 350 days over the three-year period—continued to show better intellectual functioning. The more they attended, the higher they scored, with greater gains among those whose birth weights were higher—between 4½ and 5½ pounds (2,001 to 2,500 grams) (see Figure 4.5). In contrast, children who attended only sporadically gained little or even lost ground (Hill, Brooks-Gunn, & Waldfogel, 2003). A follow-up at age 18 revealed persisting benefits for the higher-birth-weight participants: They remained advantaged over controls in academic achievement, and they also engaged in fewer risky behaviors such as unprotected sexual activity and alcohol and drug use (McCormick et al., 2006).

These findings confirm that babies who are both preterm and economically disadvantaged require intensive intervention. And special strategies, such as extra adult–child interaction both at home and in infant–toddler and early childhood programs, may be necessary to achieve lasting changes in children with the lowest birth weights.

Nevertheless, even the best environments cannot always overcome the enormous biological risks associated with being born extremely preterm and underweight. Think back to Keith, the very sick baby you met at the beginning of this section. Despite advanced medical technology and new ways of helping parents, most infants born as early and with as low a birth weight as Keith either die or end up with serious disabilities (refer again to Figure 4.5). Six months after he was born, Keith died without ever having left the hospital.

Although Keith’s premature birth was unavoidable, the high rate of underweight babies in the United States—one of the worst in the industrialized world—can be greatly reduced by improving the health and social conditions described in the Cultural Influences box on page 132. Fortunately, today we can save many preterm babies, but an even better course of action would be to prevent this serious threat to infant survival and development before it happens.

Figure 4.5 Influence of intensity of early intervention for low-income, preterm babies on intellectual functioning at age 8. Infants born preterm received cognitively stimulating child care from 1 through 3 years of age. Those who attended the program sporadically gained little in intellectual functioning (heavier-weight babies) or lost ground (lighter-weight babies). The more often children attended, the greater their intellectual gains. Heavier babies consistently gained more than light babies. But boosting the intensity of intervention above 400 days led to a dramatic increase in the performance of the light-weight group. (Adapted from Hill, Brooks-Gunn, & Waldfogel, 2003.)

4.4.3 Birth Complications, Parenting, and Resilience

In the preceding sections, we considered major birth complications. Now let’s try to put the evidence together. Can any general principles help us understand how infants who survive a traumatic birth are likely to develop? A landmark study carried out in Hawaii provides answers to this question.

In 1955, Emmy Werner and Ruth Smith began to follow the development of nearly 700 infants on the island of Kauai who experienced either mild, moderate, or severe birth complications. Each was matched, on the basis of SES and ethnicity, with a healthy newborn (Werner & Smith, 1982). The children were monitored in childhood and adolescence and at ages 32 and 40 in adulthood.

Findings revealed that the likelihood of long-term difficulties increased if birth trauma was severe. Among participants with mild to moderate birth complications, those growing up in stable families with sensitive, involved parenting fared almost as well on measures of intelligence and psychological adjustment as those with no birth complications. Children exposed to poverty, family disorganization, and mentally ill parents often developed serious learning difficulties, behavior problems, and emotional disturbance.

The Kauai study tells us that as long as birth injuries are not overwhelming, a supportive home can restore children’s development. But the most intriguing cases in this study were the handful of exceptions. A few children with both fairly serious birth complications and troubled family environments grew into competent adults who fared as well as controls in physical and mental health and vocational attainment. Werner and Smith found that these children relied on factors outside the family and within themselves to overcome stress. Some had attractive personalities—cheerfulness, agreeableness, and sociability—that drew positive responses from relatives, neighbors, and peers. In other instances, a grandparent, aunt, uncle, or babysitter provided the needed emotional support (Werner, 2001, 2005; Werner & Smith, 1992).

Do these outcomes remind you of the characteristics of resilient children, discussed in Chapter 1? The Kauai study and other similar investigations reveal that the impact of early biological risks often wanes as children’s personal characteristics and social experiences contribute increasingly to their functioning (Werner, 2013). In sum, when the overall balance of life events tips toward the favorable side, children with serious birth problems can develop successfully. And when negative factors outweigh positive ones, even a sturdy newborn can become a lifelong casualty.

Cultural InfluencesA Cross-National Perspective on Health Care and Other Policies for Parents and Newborn Babies

Infant mortality—the number of deaths in the first year of life per 1,000 live births—is an index used around the world to assess the overall health of a nation’s children. Although the United States has the most up-to-date health-care technology in the world, it has made less progress in reducing infant deaths than many other countries. Over the past three decades, it has slipped in the international rankings, from seventh in the 1950s to thirty-ninth in 2018 (see Figure 4.6). Members of America’s poor ethnic minorities are at greatest risk, with African-American infants more than twice as likely as white infants to die in the first year of life (U.S. Census Bureau, 2018b).

Neonatal mortality, the rate of death within the first month of life, accounts for 67 percent of the infant death rate in the United States. Two factors are largely responsible for neonatal mortality. The first is serious physical defects, most of which cannot be prevented. The percentage of babies born with physical defects is about the same in all ethnic and income groups. The second leading cause of neonatal mortality is low birth weight, which is largely preventable.

Widespread poverty and inadequate health-care programs for mothers and young children are largely responsible for these trends. In addition to providing government-sponsored health-care benefits to all citizens, each country in Figure 4.6 that outranks the United States in infant survival takes extra steps to make sure that pregnant mothers and babies have access to good nutrition, high-quality medical care, and social and economic supports that promote effective parenting.

For example, all Western European nations guarantee women a certain number of prenatal visits at very low or no cost. After a baby is born, a health professional routinely visits the home to provide counseling about infant care and to arrange continuing medical services. Home assistance is especially extensive in the Netherlands (Lamkaddem et al., 2014). For a token fee, each mother is granted a specially trained maternity helper, who assists with infant care, shopping, housekeeping, meal preparation, and the care of other children for 8 to 10 days after delivery.

Paid, job-protected employment leave is another vital societal intervention for new parents. Canadian mothers are eligible for 15 weeks maternity leave at 55 percent of prior earnings (up to a maximum of $413 per week), and Canadian mothers or fathers can take an additional 35 weeks of parental leave at the same rate. Sweden has the most generous parental leave program in the world. Mothers can begin maternity leave 60 days prior to expected delivery and extend it to 6 weeks after birth; fathers are granted two weeks of birth leave. In addition, either parent can take full leave for 15 months at 80 percent of prior earnings, followed by an additional three months at a modest flat rate. Each parent is also entitled to another 18 months of unpaid leave. Even economically less well-off nations provide parental leave benefits. In Bulgaria, new mothers are granted 11 months paid leave, and fathers receive 3 weeks (Addati, Cassirer, & Gilchrist, 2014).

Yet in the United States, the federal government mandates only 12 weeks of unpaid leave for employees in companies with at least 50 workers. Most women, however, work in smaller businesses, and many of those who work in large enough companies cannot afford to take unpaid leave. And because of financial pressures, many new mothers who are eligible for unpaid work leave take far less than 12 weeks. Similarly, though paternal leave—especially, 2 weeks or more—predicts fathers’ increased involvement in child care and is linked to improved cognitive development in the early years, fathers typically take less than 10 days or none at all (Huerta et al., 2013).

Description

Figure 4.6 Infant mortality in 39 nations. Despite its advanced health-care technology, the United States ranks poorly. It is thirty-ninth in the world, with a death rate of 5.7 infants per 1,000 births. (Based on U.S. Census Bureau, 2018b.)

In 2002, California became the first state to guarantee a mother or father paid leave—up to 6 weeks at half salary, regardless of the size of the company. Since then, the District of Columbia, Hawaii, New Jersey, New York, Rhode Island, Washington, and the territory of Puerto Rico have passed similar legislation.

Nevertheless, 6 weeks of childbirth leave (the norm in the United States) is not enough. Leaves of 6 to 8 weeks or less are linked to increased maternal anxiety, depression, sense of role overload (conflict between work and family responsibilities), and negative interactions with the baby. A leave of 12 weeks or more predicts favorable maternal physical and mental health, supportive marital interaction, and sensitive caregiving (Aitken et al., 2015; Feldman, Sussman, & Zigler, 2004). Single women and their babies are most hurt by the absence of a generous national paid-leave policy. These mothers, who are usually the sole source of support for their families, can least afford to take time from their jobs.

A Swedish father takes advantage of his country’s generous parental leave program to care for and bond with his baby. Paternal leave of 2 weeks or more is linked to improved cognitive development in the early years.

JONATHAN NACKSTRAND/AFP via Getty Images

In countries with low infant mortality rates, expectant parents need not wonder how they will access essential resources for supporting their baby’s development. The powerful impact of universal, high-quality health care; generous parental leave; and other social services on maternal and infant well-being provides strong justification for these policies. Responding to these findings, the U.S. Affordable Care Act provides generous grants to the states to cover the cost of evidence-based home-visiting programs that provide comprehensive services to mothers, infants, and young children in high-risk families.

Ask Yourself

Connect ■ List factors discussed in this chapter and in Chapter 3 that increase the chances of an infant being born underweight. How many of these factors could be prevented by better health care for expectant mothers?

Apply ■ Cecilia and Anna each gave birth to a 3-pound baby seven weeks preterm. Cecilia is single and on welfare. Anna and her husband are happily married and earn a good income. Plan an intervention appropriate for helping each baby develop.

Reflect ■ Many people object to the use of extraordinary medical measures to save extremely low-birth-weight babies because of their high risk for serious developmental problems. Do you agree or disagree? Explain.

4.5 THE NEWBORN BABY’S CAPACITIES

4.5a Describe the newborn baby’s reflexes and states of arousal, including sleep characteristics and ways to soothe a crying baby.

4.5b Describe the newborn baby’s sensory capacities.

4.5c Explain the usefulness of neonatal behavioral assessment.

Newborn infants have a remarkable set of capacities that are crucial for survival and for evoking adult attention and care. In relating to the physical and social world, babies are active from the very start.

4.5.1 Reflexes

A reflex is an inborn, automatic response to a particular form of stimulation. Reflexes are the newborn baby’s most obvious organized patterns of behavior. As Jay placed Joshua on a table in my classroom, we saw several. When Jay bumped the side of the table, Joshua reacted by flinging his arms wide and bringing them back toward his body. As Yolanda stroked Joshua’s cheek, he turned his head in her direction. When she put her finger in Joshua’s palm, he grabbed on tightly. Look at Table 4.2 and see if you can name the newborn reflexes that Joshua displayed. Let’s consider the meaning and purpose of these curious behaviors.

Adaptive Value of Reflexes

Some reflexes have survival value. The rooting reflex helps a breastfed baby find the mother’s nipple. Babies display it only when hungry and touched by another person, not when they touch themselves (Rochat & Hespos, 1997). At birth, babies adjust their sucking pressure to how easily milk flows from the nipple (Craig & Lee, 1999). And if sucking were not automatic, our species would be unlikely to survive for a single generation! The swimming reflex helps a baby who is accidentally dropped into water stay afloat, increasing the chances of retrieval by the caregiver.

Other reflexes probably helped babies survive during our evolutionary past. For example, the Moro, or “embracing,” reflex is believed to have helped infants cling to their mothers when they were carried about all day. If the baby happened to lose support, the reflex caused the infant to embrace and, along with the palmar grasp reflex (so strong during the first week that it can support the baby’s entire weight), regain its hold on the mother’s body. Another conjecture is that the Moro embracing motion signals the caregiver to pick up and comfort a startled infant (Rousseau et al., 2017).

Table 4.2 Some Newborn Reflexes

Reflex

Stimulation

Response

Age of Disappearance

Function

Eye blink

Shine bright light at eyes or clap hand near head.

Infant quickly closes eyelids.

Permanent

Protects infant from strong stimulation

Rooting

Stroke cheek near corner of mouth.

Head turns toward source of stimulation.

3 weeks (becomes voluntary head turning at this time)

Helps infant find the nipple

Sucking

Place finger in infant’s mouth.

Infant sucks finger rhythmically.

Replaced by voluntary sucking after 4 months

Permits feeding

Swimminga

Occurs when infant is face down in pool of water.

Baby paddles and kicks in swimming motion.

4–6 months

Helps infant survive if dropped into water

Moro

Hold infant horizontally on back and let head drop slightly, or produce a sudden loud sound against surface supporting infant.

Infant makes an “embracing” motion by arching back, extending legs, throwing arms outward, spreading fingers, and then bringing arms in toward the body.

6 months

In human evolutionary past, may have helped infant cling to caregiver or (through extension of arms) signal caregiver to pick up baby

Palmar grasp

Place finger in infant’s hand and press against palm.

Spontaneous grasp of finger

3–4 months

Prepares infant for voluntary grasping

Tonic neck

Turn baby’s head to one side while infant is lying awake on back.

Infant lies in a “fencing position.” One arm is extended in front of eyes on side to which head is turned; other arm is flexed.

4 months

May prepare infant for voluntary reaching

Stepping

Hold infant under arms and permit bare feet to touch a flat surface.

Infant lifts one foot after another in stepping response.

Replaced by voluntary walking at end of the first year

Prepares infant for voluntary walking

Babinski

Stroke sole of foot from toe toward heel.

Toes fan out and curl as foot twists in.

8–12 months

Unknown

aPlacing infants in a pool of water is dangerous. See discussion on page 136 in this section.

Sources: Knobloch & Pasamanick, 1974; Rousseau et al., 2017; Thelen, Fisher, & Ridley-Johnson, 1984.

Several reflexes help parents and infants establish gratifying interaction. A baby who successfully finds the nipple, sucks easily during feedings, grasps when her hand is touched, or induces the caregiver to pick her up encourages parents to respond lovingly and feel competent as caregivers. Reflexes that help infants control distress can also aid parents in comforting the baby. For example, on outings with Joshua, Yolanda brought along a pacifier. If he became fussy, sucking helped quiet him until she could feed, change, or hold him.

In the Moro reflex, loss of support or a sudden loud sound causes the baby to arch her back, extend her arms outward, and then bring them in toward her body.

© LAURA DWIGHT PHOTOGRAPHY

Reflexes and the Development of Motor Skills

A few reflexes form the basis for complex motor skills that will develop later. For example, the tonic neck reflex may prepare the baby for voluntary reaching. When infants lie on their backs in this “fencing position,” they naturally gaze at the hand in front of their eyes. The reflex may encourage them to combine vision with arm movements and, eventually, reach for objects.

The palmar grasp reflex is so strong during the first week after birth that many infants can use it to support their entire weight.

© LAURA DWIGHT PHOTOGRAPHY

Certain reflexes—such as the palmar grasp, swimming, and stepping—drop out early, but the motor functions involved are renewed later. The stepping reflex, for example, looks like a primitive walking response. Around 2 months, it declines as infants increasingly relax their limbs, flexing their legs at the hip and knees when lowered onto a flat surface, which inhibits stepping. But if babies are held upright in the air, the reflex is clearly evident and persists, over time being integrated into independent walking (Barbu-Roth et al., 2015). Furthermore, when stepping is exercised regularly, babies make more reflexive stepping movements and are likely to walk several weeks earlier than if stepping is not practiced (Zelazo et al., 1993). However, there is no special need for infants to practice the stepping reflex because all typically developing babies walk in due time.

In the tonic neck reflex, infants lie on their backs in a “fencing position,” which may help prepare them for voluntary reaching.

© LAURA DWIGHT PHOTOGRAPHY

When held upright under the arms, newborn babies show reflexive stepping movements.

© LAURA DWIGHT PHOTOGRAPHY

In the case of the swimming reflex, trying to build on it is risky. Although young infants placed in a swimming pool will paddle and kick, they swallow large amounts of water. This lowers the sodium concentration in the baby’s blood, which can cause brain swelling and seizures. Despite this remarkable reflex, swimming lessons are best postponed until at least 3 years of age.

The Importance of Assessing Newborn Reflexes

Look at Table 4.2 again, and you will see that most newborn reflexes disappear during the first six months. Researchers believe that this is due to a gradual increase in voluntary control over behavior as the cerebral cortex develops.

Pediatricians test reflexes carefully, especially if a newborn has experienced birth trauma, because reflexes can reveal the health of the baby’s nervous system. Weak or absent reflexes, overly rigid or exaggerated reflexes, and reflexes that persist beyond the point in development when they should normally disappear can signal brain damage (Schott & Rossor, 2003). However, individual differences in reflexive responses exist that are not cause for concern. An observer must assess reflexes along with other infant attributes to accurately distinguish typical from atypical central nervous system functioning.

4.5.2 States

Throughout the day and night, newborn infants move in and out of the five states of arousal, or degrees of sleep and wakefulness, described in Table 4.3. During the first month, these states alternate frequently. The most fleeting is quiet alertness, which usually moves quickly toward fussing and crying. Much to the relief of their fatigued parents, newborns spend the greatest amount of time asleep—about 16 to 18 hours a day. And even those who are as much as 8 weeks preterm are responsive to regular periods of darkness and light in their surroundings, increasingly sleeping more at night than during the day over the early weeks (Figueiredo et al., 2016; Guyer et al., 2015). Nevertheless, young babies’ sleep–wake cycles are affected more by fullness–hunger than by darkness–light (Davis, Parker, & Montgomery, 2004).

4.However, striking individual differences in daily rhythms exist that affect parents’ attitudes toward and interactions with the baby. A few newborns sleep for long periods, increasing the energy their well-rested parents have for sensitive, responsive care. Other babies wake frequently and cry often, and their parents must exert great effort to soothe them. If these parents do not succeed, they may feel less competent and less positive toward their infant. Babies who spend more time alert probably receive more social stimulation and opportunities to explore and, therefore, may have a slight advantage in cognitive development.

Table 4.3 Infant States of Arousal

State

Description

Daily Duration in Newborn

Regular, or NREM, sleep

The infant is at full rest and shows little or no body activity. The eyelids are closed, no eye movements occur, the face is relaxed, and breathing is slow and regular.

8–9 hours

Irregular, or REM, sleep

Gentle limb movements, occasional stirring, and facial grimacing occur. Although the eyelids are closed, occasional rapid eye movements can be seen beneath them. Breathing is irregular.

8–9 hours

Drowsiness

The infant is either falling asleep or waking up. Body is less active than in irregular sleep but more active than in regular sleep. The eyes open and close; when open, they have a glazed look. Breathing is even but somewhat faster than in regular sleep.

Varies

Quiet alertness

The infant’s body is relatively inactive, with eyes open and attentive. Breathing is even.

2–3 hours

Waking activity and crying

The infant shows frequent bursts of uncoordinated body activity. Breathing is very irregular. Face may be relaxed or tense and wrinkled. Crying may occur.

1–4 hours

Source: Wolff, 1966

As with adults, sleep contributes to babies’ learning and memory. In two studies, eye-movement responses and brain-wave recordings revealed that sleeping newborns readily learned that a tone would be followed by a puff of air to the eye (Fifer et al., 2010; Tarullo et al., 2015). Because young infants spend so much time sleeping, the capacity to learn about external stimuli during sleep may be essential for adaptation to their surroundings.

Of the states listed in Table 4.3, the two extremes—sleep and crying—have been of greatest interest to researchers. Each tells us something about normal and abnormal early development.

Sleep

Observing Joshua as he slept, Yolanda and Jay wondered why his eyelids and body twitched and his rate of breathing varied. Sleep is made up of at least two states. During irregular, or rapid-eye-movement (REM), sleep, brain-wave activity is remarkably similar to that of the waking state. The eyes dart beneath the lids; heart rate, blood pressure, and breathing are uneven; and slight body movements occur. The expression “sleeping like a baby” was probably not meant to describe this state! In contrast, during regular, or non-rapid-eye-movement (NREM), sleep, the body is almost motionless, and heart rate, breathing, and brain-wave activity are slow and even.

Like children and adults, newborns alternate between REM and NREM sleep. However, they spend far more time in the REM state than they ever will again. REM sleep accounts for 50 percent of the newborn baby’s sleep time. By 3 to 5 years, it has declined to an adultlike level of 20 percent (Korotchikova et al., 2016; Louis et al., 1997).

Why do young infants spend so much time in REM sleep? In older children and adults, the REM state is associated with dreaming. Babies probably do not dream, at least not in the same way we do. But researchers believe that the stimulation of REM sleep is vital for growth of the central nervous system (Tarullo, Balsam, & Fifer, 2011). Young infants seem to have a special need for this stimulation because they spend little time in an alert state, when they can get input from the environment. In support of this idea, the percentage of REM sleep is especially great in the fetus and in preterm babies, who are even less able than full-term newborns to take advantage of external stimulation (Peirano, Algarin, & Uauy, 2003).

Because newborn babies’ normal sleep behavior is organized and patterned, observations of sleep states can help identify central nervous system abnormalities. Infants who are brain-damaged or who have experienced birth trauma often have disturbed REM–NREM sleep cycles. Both full-term and preterm babies with poor sleep organization are likely to be behaviorally disorganized and, therefore, to have difficulty learning and eliciting interactions from caregivers that enhance their development. In follow-ups during the preschool years, they show delayed motor, cognitive, and language development (Feldman, 2006; Holditch-Davis, Belyea, & Edwards, 2005; Weisman et al., 2011). And the brain-functioning problems that underlie newborn sleep irregularities may culminate in sudden infant death syndrome, a major cause of infant mortality (see the Social Issues: Health box on page 138).

Crying

Crying is the first way that babies communicate, letting parents know that they need food, comfort, or stimulation. During the weeks after birth, all babies seem to have some fussy periods when they are difficult to console. But most of the time, the nature of the cry, combined with the experiences that led up to it, help guide parents toward its cause. The baby’s cry is a complex stimulus that varies in intensity from a whimper to a message of all-out distress (Wood, 2009). As early as the first few weeks, infants can be identified by the unique vocal “signature” of their cries, which helps parents locate their baby from a distance (Gustafson, Green, & Cleland, 1994).

To soothe his crying infant, this father lifts her to his shoulder, holds her against his gently moving body, and speaks softly to her. This combination of physical contact, upright posture, motion, and gentle sounds causes infants to stop crying and become quietly alert.

© LAURA DWIGHT PHOTOGRAPHY

Young infants usually cry because of physical needs, most commonly hunger, but may also cry in response to a change in temperature when undressed, a sudden noise, or a painful stimulus. Newborns (as well as older infants up to age 6 months) often cry at the sound of another crying baby—a response that may reflect an inborn capacity to react to the suffering of others (Dondi, Simion, & Caltran, 1999; Geangu et al., 2010). Furthermore, crying typically increases during the early weeks, peaks at about 4 to 6 weeks, and then declines (Barr, 2001). Because this trend appears in many cultures with vastly different infant care practices, researchers believe that normal readjustments of the central nervous system underlie it.

Social Issues: HealthThe Mysterious Tragedy of Sudden Infant Death Syndrome

Millie awoke with a start one morning and looked at the clock. It was 7:30, and 3-month-old Sasha had missed both her night waking and her early morning feeding. Wondering if she was all right, Millie tiptoed into Sasha’s room. She lay still under her blanket. Sasha had died silently during her sleep.

Sasha was a victim of sudden infant death syndrome (SIDS), the unexpected death, usually during the night, of an infant younger than 1 year of age that remains unexplained after thorough investigation. In industrialized nations, SIDS is the leading cause of infant mortality between 1 and 12 months, accounting for about 20 percent of these deaths in the United States (Centers for Disease Control and Prevention, 2018e).

SIDS victims usually show physical problems from the beginning. Early medical records of SIDS babies reveal higher rates of prematurity and low birth weight, poor Apgar scores, and limp muscle tone. Abnormal heart rate and respiration and disturbances in sleep–wake activity and in REM–NREM cycles while asleep are also involved (Cornwell & Feigenbaum, 2006; Garcia, Koschnitzky, & Ramirez, 2013). At the time of death, many SIDS babies have a mild respiratory infection (Blood-Siegfried, 2009). This seems to increase the chances of respiratory failure in an already vulnerable baby.

Mounting evidence indicates that impaired brain functioning is a major contributor to SIDS. Between 2 and 4 months, when SIDS is most likely to occur, reflexes decline and are replaced by voluntary, learned responses. Neurological weaknesses may prevent SIDS babies from acquiring voluntary behaviors that replace defensive reflexes (Horne, 2017; Rubens & Sarnat, 2013). As a result, when breathing difficulties occur during sleep, these infants do not wake up, shift their position, or cry out for help. Instead, they simply give in to oxygen deprivation and death. In support of this interpretation, autopsies reveal that the brains of SIDS victims contain unusually low levels of serotonin (a brain chemical that assists with arousal when survival is threatened) as well as other abnormalities in centers that control breathing and arousal (Salomonis, 2014).

Several environmental factors are linked to SIDS. Maternal cigarette smoking, both during and after pregnancy, as well as smoking by other caregivers, doubles risk of the disorder. Infants exposed to cigarette smoke arouse less easily from sleep and have more respiratory infections (Blackwell et al., 2015). Prenatal abuse of drugs that depress central nervous system functioning (alcohol, opiates, and barbiturates) increases the risk of SIDS as much as fifteen-fold (Hunt & Hauck, 2006; Maguire et al., 2016).

SIDS babies are also more likely to sleep on their stomachs than on their backs and often are wrapped very warmly in clothing and blankets. Infants who sleep on their stomachs less often wake when their breathing is disturbed, especially if they suffer from biological vulnerabilities (Richardson, Walker, & Horne, 2008). In other cases, healthy babies sleeping face down in soft bedding may suffocate from continually breathing their own exhaled breath, resulting in accidental deaths that would be incorrectly classified as SIDS.

SIDS rates are especially high among poverty-stricken ethnic minorities (Centers for Disease Control and Prevention, 2018e). In these families, parental stress, substance abuse, reduced access to health care, and lack of knowledge about safe sleep practices are widespread.

Dissemination of information to parents encouraging them to put their infants down on their backs to sleep has helped reduce the incidence of SIDS by more than half.

© BFG Images/Getty Images

The U.S. government’s Safe to Sleep campaign encourages parents to create safe sleep environments and engage in other protective practices (National Institutes of Health, 2018a). Recommendations include quitting smoking and drug taking, placing infants on their backs in light sleep clothing, providing a firm sleep surface, and eliminating soft bedding. An estimated 20 percent of SIDS cases would be prevented if all infants had smoke-free homes. Dissemination of information to parents about putting infants down on their backs has cut the incidence of SIDS by more than half (Behm et al., 2012). Other protective measures are breastfeeding, perhaps because it offers protection against respiratory infections (see Chapter 5), and pacifier use at bedtime: Sleeping babies who suck arouse more easily in response to breathing and heart-rate irregularities (Alm et al., 2016).

When SIDS does occur, surviving family members require a great deal of help to overcome a sudden and unexpected death. As Millie commented six months after Sasha’s death, “It’s the worst crisis we’ve ever been through. What’s helped us most are the comforting words of others who’ve experienced the same tragedy.”

The next time you hear a baby cry, notice your own reaction. The sound stimulates a sharp rise in alertness, the stress hormone cortisol, and feelings of arousal and discomfort in men and women, parents and nonparents alike (de Cock et al., 2015; Yong & Ruffman, 2014). This powerful response is probably innately programmed to help ensure that babies receive the care and protection they need to survive.

Applying What We Know

Soothing a Crying Baby

Technique

Explanation

Talk softly or play rhythmic sounds.

Continuous, monotonous, rhythmic sounds (such as a clock ticking, a fan whirring, or peaceful music) are more effective than intermittent sounds.

Offer a pacifier.

Sucking helps babies control their own level of arousal.

Massage the baby’s body.

Stroking the baby’s torso and limbs with continuous, gentle motions relaxes the baby’s muscles.

Swaddle the baby.

Restricting movement and increasing warmth often soothe a young infant.

Lift the baby to the shoulder and rock or walk.

This combination of physical contact, upright posture, and motion is an effective soothing technique, causing young infants to become quietly alert.

Take the baby for a short car ride or a walk in a baby carriage; swing the baby in a cradle.

Gentle, rhythmic motion of any kind helps lull the baby to sleep.

Combine several of the methods just listed.

Stimulating several of the baby’s senses at once is often more effective than stimulating only one.

If these methods do not work, let the baby cry for a short period.

Occasionally, a baby responds well to just being put down and will, after a few minutes, fall asleep.

Sources: Dayton et al., 2015; Evanoo, 2007; St James-Roberts, 2012.

Soothing Crying Infants

Although parents do not always interpret their baby’s cry correctly, their accuracy improves with experience. At the same time, they vary widely in responsiveness. Parents who are high in empathy (ability to take the perspective of others in distress) and who hold “child-centered” attitudes toward infant care (for example, believe that babies cannot be spoiled by being picked up) are more likely to respond quickly and sensitively (Cohen-Bendahan, van Doornan, & deWeerth, 2014; Leerkes, 2010).

Fortunately, there are many ways to soothe a crying baby when feeding and diaper changing do not work (see Applying What We Know above). The technique that Western parents usually try first, lifting the baby to the shoulder and rocking or walking, is highly effective. Another common soothing method is swaddling—wrapping the baby snugly in a blanket. The Quechua people of the cold, high-altitude desert regions of Peru dress young infants in several layers of clothing and blankets that cover the head and body, a technique that reduces crying and promotes sleep (Tronick, Thomas, & Daltabuit, 1994). It also allows babies to conserve energy for early growth in their harsh environment.

In many tribal and village societies and in non-Western developed nations (such as Japan and Vietnam), young infants are in physical contact with their caregivers nearly continuously. Infants in these cultures show shorter bouts of crying than their American counterparts (Barr, 2001; Murray et al., 2018). When Western parents choose to practice proximal parenting by holding their babies extensively and responding swiftly to their cries, the amount of crying in the early months is reduced by about one-third (St James-Roberts, 2012).

The Bedouin people of the Middle East tightly swaddle young infants, a practice that reduces crying and promotes sleep.

© robertharding/Alamy Stock Photo

Abnormal Crying

Like reflexes and sleep patterns, the infant’s cry offers a clue to central nervous system distress. The cries of brain-damaged babies and those who have experienced prenatal and birth complications are often shrill, piercing, and shorter in duration than the cries of healthy infants (Green, Irwin, & Gustafson, 2000). Even newborns with a fairly common problem—colic, or bouts of persistent, hard-to-soothe crying—tend to have high-pitched, harsh-sounding cries. Although the cause of colic is unknown, certain newborns, who react especially strongly to unpleasant stimuli, are susceptible. Because their crying is intense, they find it harder to calm down than other babies (St James-Roberts, 2007). Colic generally subsides between 3 and 6 months.

Most parents try to respond to a crying baby’s call for help with extra care and attention, but sometimes the cry is so unpleasant and the infant so difficult to soothe that parents become exhausted, resentful, and angry. Preterm and ill babies are more likely to be abused by highly stressed parents, who sometimes mention a high-pitched, grating cry as one factor that caused them to lose control (Barr et al., 2014; de Weerth & St James-Roberts, 2017). (We will discuss a host of additional influences on child abuse in Chapter 10.)

Look and Listen

In a public setting, watch several parents soothe their crying babies. What techniques did the parents use, and how successful were they?

In a study of a large, nationally representative sample of Dutch infants, excessive crying in the early weeks elevated the risk of child behavior problems at age 5 to 6 years, especially when mothers viewed infant care as burdensome and the crying led them to speak angrily to or slap their baby (Smarius et al., 2017). Support programs for parents can help prevent these negative outcomes. In one intervention, nurses made periodic home visits during which they taught parents to identify early warning signs that their colicky baby was becoming overly aroused, to use effective soothing techniques, and to modify light, noise, and activity in the home to promote predictable sleep–wake cycles (Keefe et al., 2005). Colicky infants in the intervention group spent far less time crying than no-intervention controls—1.3 versus 3 hours per day.

4.5.3 Sensory Capacities

On his visit to class, Joshua looked wide-eyed at Yolanda’s bright pink blouse and readily turned to the sound of her voice. During feedings, he lets Yolanda know by the way he sucks that he prefers the taste of breast milk to a bottle of plain water. Clearly, Joshua has some well-developed sensory capacities. In the following sections, we explore the newborn baby’s responsiveness to touch, taste, smell, sound, and visual stimulation.

Touch

In our discussion of preterm infants, we saw that touch helps stimulate early physical growth. And as we will see in Chapter 7, it is vital for emotional development as well. Therefore, it is not surprising that sensitivity to touch is well-developed at birth.

The reflexes listed in Table 4.2 on page 134 in section 4.6.1 reveal that the newborn baby responds to touch, especially around the mouth, on the palms, and on the soles of the feet. During the prenatal period, these areas, along with the genitals, are the first to become sensitive to touch (Humphrey, 1978; Streri, 2005). Newborns, even those born several weeks preterm, use touch to investigate their world. When small objects are placed in their palms, they can distinguish shape (prism versus cylinder) and texture (smooth versus rough), as indicated by their tendency to hold on longer to an object with an unfamiliar shape or texture than to a familiar object (Lejeune et al., 2012; Molina et al., 2015; Sann & Streri, 2007, 2008).

At birth, infants are highly sensitive to pain. If male newborns are circumcised, anesthetic is sometimes not used because of the risk of giving drugs to a very young infant. Babies often respond with a high-pitched, stressful cry and a dramatic rise in heart rate, blood pressure, palm sweating, pupil dilation, and muscle tension (Lehr et al., 2007; Warnock & Sandrin, 2004). Brain-imaging research suggests that because of central nervous system immaturity, preterm and male babies feel the pain of a medical injection especially intensely (Bartocci et al., 2006).

Certain local analgesics for newborns ease the pain of these procedures. As a supplement to pain-relieving medication, offering a nipple that delivers a sugar solution is helpful; it quickly reduces crying and discomfort in young infants, preterm and full-term alike (Roman-Rodriguez et al., 2014). Breast milk is especially effective: Even the smell of the milk of the baby’s mother reduces infant stress to a routine blood-test heel stick more readily than the odor of another mother’s milk or of formula (Badiee, Asghari, & Mohammadizadeh, 2013; Nishitani et al., 2009). Combining breastfeeding with maternal gentle holding lessens pain even more (Axelin, Salantera, & Lehtonen, 2006; Obeidat & Shuriquie, 2015). Both sweet liquid and physical touch release endorphins—painkilling chemicals in the brain.

Allowing a baby to endure severe pain overwhelms the nervous system with stress hormones, which can disrupt the child’s developing capacity to handle common, everyday stressors (Walker, 2013). The result is heightened pain sensitivity, sleep disturbances, feeding problems, and difficulty calming down when upset.

Taste and Smell

Facial expressions reveal that newborns can distinguish several basic tastes. Like adults, they relax their facial muscles in response to sweetness, purse their lips when the taste is sour, and show a distinct archlike mouth opening when it is bitter. Similarly, certain odor preferences are present at birth. For example, the smell of bananas or chocolate causes a pleasant facial expression, whereas the odor of rotten eggs makes the infant frown (Steiner, 1979; Steiner et al., 2001). These reactions are important for survival: The food that best supports the infant’s early growth is the sweet-tasting milk of the mother’s breast. Not until 4 months do babies prefer a salty taste to plain water, a change that may prepare them to accept solid foods (Mennella & Beauchamp, 1998).

During pregnancy, the amniotic fluid is rich in tastes and smells that vary with the mother’s diet—early experiences that influence newborns’ preferences. In a study carried out in the Alsatian region of France, where anise is frequently used to flavor foods, researchers tested newborns for their reaction to the anise odor (Schaal, Marlier, & Soussignan, 2000). The mothers of some babies had regularly consumed anise during the last two weeks of pregnancy; the other mothers had never consumed it. When presented with the anise odor on the day of birth, the babies of anise-consuming mothers more often displayed facial expressions of interest and liking. In contrast, those of non-anise-consuming mothers were far more likely to turn away with negative facial expressions (see Figure 4.7). These different reactions were still apparent four days later, even though all mothers had refrained from consuming anise during this time.

In some instances, exposure to a flavor, either prenatally in the amniotic fluid or during the weeks after birth in breast milk, can have long-term consequences for odor and taste preferences. Compared to newborns of mothers who rarely drank alcohol during pregnancy, newborns whose mothers had frequently consumed alcoholic drinks more often displayed positive facial expressions to the odor of alcohol in the first two weeks of life—mouthing, sucking, smiling, and sticking out their tongues (Faas et al., 2015). This prenatally influenced attraction to alcohol is still evident in adolescence and early adulthood, even after other factors known to affect alcohol intake are controlled, such as genetic predisposition assessed through family history of alcoholism (Alati et al., 2006; Baer et al., 2003).

Figure 4.7 Examples of facial expressions of newborns exposed to the odor of anise whose mothers’ diets differed in anise-flavored foods during late pregnancy. (a) Babies of anise-consuming mothers spent more time turning toward the odor and sucking, licking, and chewing. (b) Babies of non-anise-consuming mothers more often turned away with a negative facial expression. (From B. Schaal, L. Marlier, & R. Soussignan, 2000, “Human Foetuses Learn Odours from Their Pregnant Mother’s Diet,” Chemical Senses, 25, p. 731. Reprinted by permission of Oxford University Press and Benoist Schaal.)

At the same time, young infants can learn to prefer a taste that at first evoked either a negative or neutral response. Bottle-fed newborns allergic to cow’s milk formula who are given a soy or other vegetable-based substitute (typically very sour and bitter-tasting) soon prefer it to regular formula. When first given solid foods several months later, these infants display an unusual liking for bitter-tasting cereals (Beauchamp & Mennella, 2011). This taste preference is still present at age 4 to 5 years, in more positive responses to foods with sour and bitter tastes than shown by their agemates.

In mammals, including humans, the sense of smell—in addition to playing an important role in feeding—helps mothers and babies identify each other. At 2 to 4 days of age, breastfed babies prefer the odor of their own mother’s breast and underarm to that of an unfamiliar lactating woman (Cernoch & Porter, 1985; Marin, Rapisardi, & Tani, 2015). And both breast- and bottle-fed 3- to 4-day-olds orient more to the smell of unfamiliar human milk than to formula milk, indicating that (even without postnatal exposure) the odor of human milk is more attractive to newborns (Marlier & Schaal, 2005). Newborns’ dual attraction to the odors of their mother and of breast milk helps them locate an appropriate food source and, in the process, begin to distinguish their caregiver from other people.

Hearing

Although conduction of sound through the structures of the ear and transmission of auditory information to the brain are inefficient at birth, newborn infants can hear a wide variety of sounds—sensitivity that improves greatly over the first few months (Johnson & Hannon, 2015). At birth, infants prefer complex sounds, such as noises and voices, to pure tones. And babies only a few days old can tell the difference between a variety of sound patterns: a series of tones arranged in ascending versus descending order; tone sequences with a rhythmic downbeat (as in music) versus those without; utterances with two versus three syllables; the stress patterns of words, such as “ma-ma” versus “ma-ma”; happy-sounding speech as opposed to speech with negative or neutral emotional qualities; and even two languages spoken by the same bilingual speaker, as long as those languages differ in their rhythmic features—for example, French versus Russian (Mastropieri & Turkewitz, 1999; Ramus, 2002; Sansavini, Bertoncini, & Giovanelli, 1997; Trehub, 2001; Winkler et al., 2009).

Young infants listen longer to human speech than to structurally similar nonspeech sounds (Vouloumanos, 2010). And they can detect the sounds of any human language. Newborns make fine-grained distinctions among many speech sounds. For example, when given a nipple that turns on a recording of the “ba” sound, babies suck vigorously for a while and then slow down as the novelty wears off. When the sound switches to “ga,” sucking picks up, indicating that infants detect this subtle difference. Using this method, researchers have found only a few speech sounds that newborns cannot discriminate. Their ability to perceive sounds not found in their own language is more precise than an adult’s (Jusczyk & Luce, 2002). These capacities, which build on the fetus’s sensitivity to human speech in the weeks before birth (see page 96 in Chapter 3), reveal that the baby is marvelously prepared for the awesome task of acquiring language.

Responsiveness to sound also supports the newborn baby’s exploration of the environment. Infants as young as 3 days turn their eyes and head in the general direction of a sound. The ability to identify the precise location of a sound improves greatly over the first six months and shows further gains through the preschool years (Litovsky & Ashmead, 1997).

Listen carefully to yourself the next time you talk to a young baby. You will probably speak in ways that highlight important parts of the speech stream—using a slow, high-pitched, expressive voice with a rising tone at the ends of phrases and sentences and pausing before continuing. Adults probably communicate this way with infants because they notice that babies are more attentive when they do so. Indeed, newborns prefer speech with these characteristics: On hearing it, they focus more intently on the speaker’s face (Guellaï et al., 2016; Saffran, Werker, & Werner, 2006). They will also suck more on a nipple to hear a recording of their own mother’s voice than that of an unfamiliar woman and to hear their native language as opposed to a foreign language (Moon, Cooper, & Fifer, 1993; Spence & DeCasper, 1987). These preferences probably developed from hearing the muffled sounds of the mother’s voice before birth.

A newborn baby, primed and ready for the awesome task of acquiring language, gazes intently at his mother, listening attentively as she talks to him.

© LAURA DWIGHT PHOTOGRAPHY

Vision

Vision is the least-developed of the newborn baby’s senses. Visual structures in both the eye and the brain are not yet fully formed at birth. For example, cells in the retina, the membrane lining the inside of the eye that captures light and transforms it into messages that are sent to the brain, are not as mature or densely packed as they will be in several months. The optic nerve that relays these messages, and visual centers in the brain that receive them, will not be adultlike for several years. And muscles of the lens, which permit us to adjust our visual focus to varying distances, are weak (Johnson & Hannon, 2015).

As a result, newborns cannot focus their eyes well, and their visual acuity, or fineness of discrimination, is limited. At birth, infants perceive objects at a distance of 20 feet about as clearly as adults do at 600 feet (Slater et al., 2010). In addition, unlike adults (who see nearby objects most clearly), newborn babies see unclearly across a wide range of distances (Banks, 1980; Hainline, 1998). As a result, images such as the parent’s face, even from close up, look like the blurry image in Figure 4.8. Nevertheless, as we will see in Chapter 5, newborns can detect human faces. And as with their preference for their mother’s smell and voice, from repeated exposures they quickly learn to prefer her face to that of an unfamiliar woman, although they are more sensitive to its broad outlines than its fine-grained, internal features (Bartrip, Morton, & de Schonen, 2001; Walton, Armstrong, & Bower, 1998).

Figure 4.8 View of the human face by the newborn and the adult. The newborn baby’s limited focusing ability and poor visual acuity lead the mother’s face, even when viewed from close up, to look much like the fuzzy image in (a) rather than the clear image in (b). Also, newborn infants have some color vision, although they have difficulty discriminating colors. Researchers speculate that colors probably appear similar, but less intense, to newborns than to older infants and adults. (From Kellman & Arterberry, 2006; Slater et al., 2010.)

Although they cannot yet see well, newborns actively explore their environment by scanning it for interesting sights and tracking moving objects. However, their eye movements are slow and inaccurate (von Hofsten & Rosander, 1998). Joshua’s captivation with my pink blouse reveals that he is attracted to bright objects. Nevertheless, once newborns focus on an object, they tend to look only at a single feature—for example, the corner of a triangle instead of the entire shape. And despite their preference for colored over gray stimuli, newborn babies are not yet good at discriminating colors. It will take about four months for color vision to become adultlike (Johnson & Hannon, 2015).

4.5.4 Neonatal Behavioral Assessment

A variety of instruments permit doctors, nurses, and researchers to assess the behavior of newborn babies. The most widely used of these tests, T. Berry Brazelton’s Neonatal Behavioral Assessment Scale (NBAS), evaluates the newborn’s reflexes, muscle tone, state changes, responsiveness to physical and social stimuli, and other reactions (Brazelton & Nugent, 2011). An instrument consisting of similar items, the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS), is specially designed for use with newborns at risk for developmental problems because of low birth weight, preterm delivery, prenatal substance exposure, or other conditions (Tronick & Lester, 2013). Scores are used to recommend appropriate interventions and to guide parents in meeting their baby’s unique needs.

The NBAS has been given to many infants around the world, enabling researchers to learn about individual and cultural differences in newborn behavior. For example, compared with scores of European-American infants, NBAS scores of Asian- and Native-American babies reveal less irritability. Mothers in these cultures often encourage their babies’ calm dispositions through holding and nursing at the first signs of discomfort (Muret-Wagstaff & Moore, 1989; Small, 1998). The Kipsigis of Kenya, who highly value infant motor maturity, massage babies regularly and begin exercising the stepping reflex shortly after birth. These customs contribute to Kipsigis babies’ strong but flexible muscle tone at 5 days of age (Super & Harkness, 2009). Newborns whose mothers experienced depression during pregnancy score considerably lower than those of nondepressed mothers in neurobehavioral maturity (Figueiredo et al., 2017). But with warm, attentive caregiving, NBAS scores can readily improve. In Zambia, Africa, close mother–infant contact throughout the day quickly changed the poor NBAS scores of undernourished newborns (Brazelton, Koslowski, & Tronick, 1976). At age 1 week, these unresponsive infants appeared alert, responsive, and content.

A Senegalese mother carries her baby in a sling throughout the day, a practice that maintains close physical contact, enables nursing at the first signs of discomfort, and promotes a calm, contented state.

Inger Vandyke / VWPics / Alamy Stock Photo

Because newborn behavior and parenting combine to influence development, changes in scores over the first week or two of life (rather than a single score) provide the best estimate of the baby’s ability to recover from the stress of birth. NBAS “recovery curves” predict intelligence and absence of emotional and behavior problems with moderate success well into the preschool years (Brazelton, Nugent, & Lester, 1987; Ohgi et al., 2003a, 2003b).

In some hospitals, health professionals use the NBAS or the NNNS to help parents get to know their newborns through discussion or demonstration of the capacities these instruments assess. Parents who participate in these programs, compared with no-intervention controls, interact more confidently and effectively with their babies (Browne & Talmi, 2005; Bruschweiler-Stern, 2004). Although lasting effects on development have not been demonstrated, NBAS-based interventions are useful in helping the parent–infant relationship get off to a good start.

Ask Yourself

Connect ■ How do the diverse capacities of newborn babies contribute to their first social relationships? Provide as many examples as you can.

Apply ■ After a difficult delivery, Jackie observes her 2-day-old daughter, Kelly, being given the NBAS. Kelly scores poorly on many items. Seeing this, Jackie wonders if Kelly will develop normally. How would you respond to Jackie’s concern?

Reflect ■ Are newborns more competent than you thought they were before you read this chapter? Which of their capacities most surprised you?

4.6 THE TRANSITION TO PARENTHOOD

4.6a Discuss the influence of birth-related hormonal changes and parent–infant contact on emergence of parental affection and concern for the newborn.

4.6b Describe changes in the family after the birth of a baby, along with interventions that foster the transition to parenthood.

Yolanda and Jay’s account of Joshua’s birth in the opening to this chapter revealed that holding and touching him after delivery was an experience filled with intense emotion. Most parents are overjoyed at their baby’s arrival, describe the experience as “awesome,” “indescribable,” or “unforgettable,” and display intense interest in their newborn child—stroking the baby gently, looking into the infant’s eyes, and speaking softly.

As we will see, effective caregiving is so crucial for infant survival and optimal development that nature helps prepare mothers and fathers for their new role. Yet biological changes are but one dimension of this transformative time of life. The transition to parenthood is a complex, often stressful process involving profound alterations in family roles, relationships, and responsibilities. Parents who find productive ways of overcoming difficulties adjust well, with great benefits for the parent–infant relationship.

4.6.1 Early Parent–Infant Contact

Toward the end of pregnancy, mothers begin producing higher levels of the hormone oxytocin, which causes the breasts to “let down” milk; induces a calm, relaxed mood; and heightens responsiveness to the newborn (Gordon et al., 2010; Gregory et al., 2015). Fathers, too, show hormonal changes around the time of birth that are compatible with those of mothers—specifically, slight increases in prolactin (a hormone that stimulates milk production in females), estrogens (sex hormones produced in larger quantities in females), and oxytocin, and a decrease in androgens (sex hormones produced in larger quantities in males) (Storey & Zigler, 2016). These changes, which are induced by a warm couple relationship and fathers’ contact with mother and baby, predict paternal involvement and sensitive interactions with infants (Abraham et al., 2014; Edelstein et al., 2017; Feldman, 2014).

Do human parents require close physical contact in the hours after birth for bonding, or affection and concern for the infant, to emerge—as many animal species do? Current evidence shows that the human parent–infant relationship does not depend on a precise, early period of togetherness. Some parents report sudden, deep feelings of affection on first holding their babies. For others, these emotions emerge gradually. And as successful adoption reveals (see page 64 in Chapter 2), humans can parent effectively without experiencing birth-related hormonal changes. In fact, when foster and adoptive mothers hold and interact with their nonbiological infants, they typically release oxytocin (Bick et al., 2013; Galbally et al., 2011). The greater their oxytocin production, the more they express affection and pleasure toward the infant.

Human bonding depends on many factors, not just on what happens during a short period after birth. Nevertheless, early contact with the baby may be one of several factors that help build a good parent–infant relationship. Realizing this, today hospitals offer rooming in, in which the infant stays in the mother’s hospital room all or most of the time. If parents do not choose this option or cannot do so for medical reasons, there is no evidence that their competence as caregivers will be compromised or that the baby will suffer emotionally.

A father radiates intense emotion as he gently cradles and kisses his newborn baby. Fathers, like mothers, experience hormonal changes around the time of birth that can heighten involvement and sensitive interactions with the infant.

AMELIE-BENOIST / BSIP/Alamy Stock Photo

4.6.2 Changes in the Family System

The early weeks after a baby enters the family are a taxing time for new parents. The mother needs to recover from childbirth. If she is breastfeeding, energies must be devoted to working out this intimate relationship. The other parent must become part of what is now a threesome while supporting the mother in her recovery. While all this is going on, the tiny infant is assertive about urgent physical needs, demanding to be fed, changed, and comforted at odd times of the day and night. The family schedule becomes irregular and uncertain, and parental sleep deprivation and consequent daytime fatigue are often major challenges (Insana & Montgomery-Downs, 2012). Yolanda spoke candidly about the changes she and Jay experienced:

When we brought Joshua home, he seemed so small and helpless, and we worried about whether we would be able to take proper care of him. It took us 20 minutes to change the first diaper. I rarely feel rested because I’m up two to four times every night, and I spend a good part of my waking hours trying to anticipate Joshua’s rhythms and needs. If Jay weren’t so willing to help by holding and walking Joshua, I think I’d find it much harder.

The demands of new parenthood—constant caregiving, added financial responsibilities, and less time for couples to devote to one another—usually cause parents’ gender roles to become more traditional (Katz-Wise, Priess, & Hyde, 2010; Yavorsky, Dush, & Schoppe-Sullivan, 2015). This is true even for couples like Yolanda and Jay, who are strongly committed to gender equality and are used to sharing household tasks. Yolanda took a leave of absence from work, whereas Jay’s career continued as it had before. As a result, Yolanda spent more time at home with the baby, while Jay focused more on his provider role.

For most new parents, however, the arrival of a baby—though often followed by mild declines in relationship and overall life satisfaction—does not cause significant marital strain. Marriages that are gratifying and supportive tend to remain so (Doss et al., 2009; Luhmann et al., 2012). But troubled marriages usually become more distressed after a baby is born (Houts et al., 2008). And when mothers or fathers perceive their partner as unsupportive in parenting, they experience an especially difficult post-birth adjustment (Don & Mickelson, 2014; Driver et al., 2012). For some new parents, problems are severe (see the Biology and Environment box on page 146).

Violated expectations about division of labor after childbirth powerfully affect family well-being. In dual-earner marriages, the larger the difference between men’s and women’s responsibilities for caregiving and household chores, the more conflict-ridden their interaction becomes and the more their marital satisfaction suffers, especially for women—with negative consequences for parent–infant interaction (Chong & Mickelson, 2013; Moller, Hwang, & Wickberg, 2008). In contrast, sharing caregiving and other tasks predicts greater parental happiness and sensitivity to the baby. These findings highlight the vital importance of the coparenting relationship for new parents’ adjustment and children’s development.

Biology and EnvironmentParental Depression and Child Development

About 8 to 10 percent of women experience chronic depression—mild to severe feelings of sadness and withdrawal that continue for months or years. Often, the beginnings of this emotional state cannot be pinpointed. In other instances, depression emerges or strengthens after childbirth but fails to subside (Paulson & Bazemore, 2010). This is called postpartum depression.

Although it is less recognized and studied, fathers, too, experience chronic depression. About 5 percent of fathers report symptoms after the birth of a child (Cameron, Sedov, & Tomfohr-Madsen, 2016). Parental depression can interfere with effective parenting and seriously impair children’s development. As noted in Chapter 2, genetic makeup increases the risk of depressive illness, but social and cultural factors are also involved.

Maternal Depression

During Julia’s pregnancy, her husband, Kyle, showed so little interest in their anticipated baby that Julia worried that having a child might be a mistake. Shortly after Lucy was born, Julia’s mood plunged. She felt anxious and weepy, overwhelmed by Lucy’s needs, and angry at loss of control over her own schedule. When Julia approached Kyle about her own fatigue and his unwillingness to help with the baby, he snapped that she was overreacting.

Julia’s depressed mood quickly affected her baby. In the weeks after birth, infants of depressed mothers sleep poorly, are less attentive to their surroundings, and have elevated levels of the stress hormone cortisol (Fernandes et al., 2015; Goodman et al., 2011; Natsuaki et al., 2014). The more extreme the depression and the greater the number of stressors in a mother’s life (such as marital discord, little or no social support, and poverty), the more the parent–child relationship suffers. Julia rarely smiled at, comforted, or talked to Lucy, who responded to her mother’s sad, vacant gaze by turning away, crying, and often looking sad or angry herself (Field, 2011; Vaever et al., 2015). Julia, in turn, felt guilty and inadequate, and her depression deepened. By age 6 months, Lucy showed symptoms common in babies of depressed mothers—delays in motor and cognitive development, poor emotion regulation, an irritable mood, and attachment difficulties (Ibanez et al., 2015; Lefkovics, Baji, & Rigó, 2014; Vedova, 2014).

When maternal depression persists, the parent–child relationship worsens. Depressed parents view their infants negatively, which contributes to their inept caregiving (Lee & Hans, 2015). As their children get older, lack of warmth and involvement is often accompanied by inconsistent discipline—sometimes lax, at other times too forceful (Thomas et al., 2015). As we will see in later chapters, children who experience these maladaptive parenting practices often have serious adjustment problems. Some withdraw into a depressive mood themselves; others become impulsive and aggressive (Rotheram-Fuller et al., 2018).

Paternal Depression

Paternal depression is also linked to dissatisfaction with marriage after childbirth and to other life stressors, including job loss and divorce (Bielawska-Batorowicz & Kossakowska-Petrycka, 2006; Kerstis et al., 2016). In a study of a large representative sample of British parents and babies, researchers assessed depressive symptoms of fathers shortly after birth and again the following year. Then they tracked the children’s development into the preschool years (Ramchandani et al., 2008). Persistent paternal depression was, like maternal depression, a strong predictor of child behavior problems—especially overactivity, defiance, and aggression in boys.

Paternal depression is linked to frequent father–child conflict as children grow older (Gutierrez-Galve et al., 2015). Over time, children subjected to parental negativity develop a pessimistic worldview—one in which they lack self-confidence and perceive their parents and other people as threatening. Children who constantly feel in danger are especially likely to become overly aroused in stressful situations, easily losing control in the face of cognitive and social challenges (Sturge-Apple et al., 2008). Although children of depressed parents may inherit a tendency toward emotional and behavior problems, quality of parenting is a major factor in their adjustment.

A mother discusses her postpartum depression with her doctor. Early treatment is vital for preventing parental depression from interfering with the parent–child relationship.

© FERTNIG/GETTY IMAGES

Interventions

Early treatment is vital to prevent parental depression from interfering with the parent–child relationship. Julia’s doctor referred her to a therapist, who helped Julia and Kyle with their marital problems. At times, antidepressant medication is prescribed.

In addition to alleviating parental depression, therapy that encourages depressed parents to revise their negative views of their babies and to engage in emotionally positive, responsive caregiving is vital for reducing developmental problems (Goodman et al., 2015). When a depressed parent does not respond easily to treatment, a warm relationship with the other parent or another caregiver can safeguard children’s development.

Applying What We Know

How Couples Can Ease the Transition to Parenthood

Strategy

Description

Devise a plan for sharing household tasks.

As soon as possible, discuss division of household responsibilities. Decide who does a particular chore based on who has the needed skill and time, not gender. Schedule regular times to reevaluate your plan to fit changing family circumstances.

Begin sharing child care right after the baby’s arrival.

For fathers, strive to spend equal time with the baby early. For mothers, refrain from imposing your standards on your partner. Instead, share the role of “child-rearing expert” by discussing parenting values and concerns often. Attend a new-parenthood course together.

Talk over conflicts about decision making and responsibilities.

Face conflict through communication. Clarify your feelings and needs, and express them to your partner. Listen and try to understand your partner’s point of view. Then be willing to negotiate and compromise.

Establish a balance between work and parenting.

Critically evaluate the time you devote to work in view of new parenthood. If it is too much, try to cut back.

Press for workplace and public policies that assist parents in rearing children.

Difficulties faced by new parents may be partly due to lack of workplace and societal supports. Encourage your employer to provide benefits that help combine work and family roles, such as paid employment leave, flexible work hours, and on-site, high-quality, affordable child care. Communicate with lawmakers about improving policies for children and families, including paid, job-protected leave to support the transition to parenthood.

Postponing parenthood until the late twenties or thirties, as many couples do today, eases the transition to parenthood. Waiting permits couples to pursue occupational goals, gain life experience, and strengthen their relationship. Under these circumstances, men are more enthusiastic about becoming fathers and therefore more willing to participate. And women whose careers are well under way and whose marriages are happy are more likely to encourage their husbands to share housework and child care, which fosters fathers’ involvement (Lee & Doherty, 2007; Schoppe-Sullivan et al., 2008).

A second birth typically requires that fathers take an even more active role in parenting—by caring for the firstborn while the mother is recuperating and by sharing in the high demands of tending to both a baby and a young child. Consequently, well-functioning families with a newborn second child typically pull back from the traditional division of responsibilities that occurred after the first birth. In one study, fathers in dual earner families who believed strongly in gender equality tended to be more involved with their first-borns after the second child’s arrival, particularly when the births of their two children were closely spaced (Kuo, Volling & Gonzalez, 2018). As we will see in Chapter 7, first-born children—especially those who are toddlers or young preschoolers at the time of the second birth—understandably may feel displaced and react with jealousy and anger. For strategies couples can use to ease the transition to parenthood, refer to Applying What We Know above.

The arrival of a baby profoundly changes family functioning. For couples in gratifying and supportive marriages with a positive coparenting relationship in which caregiving and household chores are shared, the stress of parenthood typically remains manageable, contributing to favorable child development.

© GCShutter/GETTY IMAGES

4.6.3 Single-Mother Families

About 40 percent of U.S. births are to single mothers, one-third of whom are teenagers (Martin et al., 2018). Although the U.S. adolescent birth rate has undergone a steady decline, it remains high compared with that of other developed nations.

At the other extreme, planned births and adoptions by never-married single 30- to 45-year-old women with at least a bachelor’s degree have doubled compared with two decades ago. Nearly one-third have at least one child (Pew Research Center, 2018e). These mothers are generally financially secure, have readily available social support from family members and friends, and adapt to parenthood with relative ease. In fact, older single mothers in well-paid occupations who plan carefully for a new baby may encounter fewer parenting difficulties than married couples, largely because their family structure is simpler: They do not have to coordinate parenting roles with a partner, and they have no unfulfilled expectations for shared caregiving (Tyano et al., 2010). Also, because of their psychological maturity, these mothers are likely to cope effectively with parenting challenges.

Look and Listen

Ask a couple or a single mother to describe the challenges of new parenthood, along with factors that aided or impeded this transition.

The majority of nonmarital births are unplanned and to women in their twenties. Most have incomes below the poverty level and experience a stressful transition to parenthood. Although many live with the baby’s father or another partner, cohabiting relationships in the United States, compared with those in Western Europe, involve less commitment and cooperation and are far more likely to break up—especially after an unplanned baby arrives (Guzzo, 2014; Jose, O’Leary, & Moyer, 2010). These single mothers often lack emotional and parenting support—strong predictors of psychological distress and infant caregiving difficulties (Keating-Lefler et al., 2004).

4.6.4 Parent Interventions

Special interventions are available to help parents adjust to life with a new baby. For those who are not at high risk for problems, counselor-led programs that focus on strengthening the couple’s relationship and their coparenting skills are particularly successful (Gottman, Gottman, & Shapiro, 2010; Schulz, Cowan, & Cowan, 2006).

In one evaluation of two brief interventions, first-time expectant couples received four 90-minute individualized coaching sessions—two shortly before birth and two 3 months after birth—aimed either at solving relationship challenges or at devising a coparenting plan for mutually supportive, shared caregiving. Compared to control-group women, those randomly assigned to either intervention reported large post-birth benefits in relationship satisfaction and in mutually supportive coparenting that were still evident two years after the birth (see Figure 4.9). Also, women experiencing the interventions were far less likely than controls to report a sharp rise in stress during their baby’s first year (Doss et al., 2014). Men also benefitted from the interventions, though not as much as women, perhaps because overall, men experience fewer difficulties during the transition to parenthood.

Figure 4.9 Impact of parent interventions focusing on the couple’s relationship and on supportive coparenting during the transition to parenthood. Ninety couples who were either married or cohabiting were randomly assigned to either a relationship-focused intervention, a coparenting-focused intervention, or a control group receiving written materials about infant care. As shown here, women receiving either intervention reported far more favorable coparenting throughout their baby’s first two years than did control-group women. Women’s relationship satisfaction with their partners showed similar post-birth trends. (From B. D. Doss et al., 2014, “A Randomized Controlled Trial of Brief Coparenting and Relationship Interventions During the Transition to Parenthood,” Journal of Family Psychology, p. 490. Copyright © 2014 American Psychological Association. Adapted by permission.)

High-risk parents struggling with poverty or the birth of a baby with disabilities need more intensive interventions. Programs in which a professional intervener visits the home and focuses on enhancing social support and parenting have resulted in improved parent–infant interaction and benefits for children’s cognitive and social development into middle childhood (to review one example, return to page 110 in Chapter 3). Many low-income single mothers benefit from interventions that focus on sustaining the father’s involvement (Jones, Charles, & Benson, 2013). These parents also require tangible support—money, food, transportation, and affordable child care—to ease stress so they have the psychological resources to engage in sensitive, responsive infant care.

When parents’ relationships are positive and cooperative, social support is available, and families have sufficient income, the stress caused by the birth of a baby remains manageable. These family conditions, as we have already seen, consistently contribute to favorable development—in infancy and beyond.

A counselor discusses options with this single mother for continuing her education. Parents struggling with poverty benefit from intensive intervention focusing on social support and effective parenting.

© CRAIG F. WALKER/GETTY IMAGES

Ask Yourself

Connect ■ Explain how generous employment leave for childbirth—at least 12 weeks of paid time off available to either the mother or father—can ease the transition to parenthood and promote positive parent–infant interaction. (Hint: Consult the Cultural Influences box on pages 132–133 in section 4.4.2.)

Apply ■ Derek, father of a 3-year-old and a newborn, reported that he had a harder time adjusting to the birth of his second child than to that of his first. Explain why this might be so.

Reflect ■ If you are a parent, what was the transition to parenthood like for you? What factors helped you adjust? What factors made it more difficult? If you are not a parent, pose these questions to someone you know who recently became a parent.

Summary

4.1 The Stages of Childbirth (p. 117)

4.1 Describe the three stages of childbirth, the baby’s adaptation to labor and delivery, and the newborn baby’s appearance.

In the first stage, dilation and effacement of the cervix occur as uterine contractions increase in strength and frequency. This stage culminates in transition, a brief period of peak contractions in which the cervix opens completely. In the second stage, the mother feels an urge to push the baby through the birth canal, and the baby is born. In the final stage, the placenta is delivered.

During labor, infants produce high levels of stress hormones, which help them withstand oxygen deprivation, clear their lungs for breathing, and arouse them into alertness.

Newborns may be odd-looking, but their facial features make adults feel like cuddling them.

The Apgar Scale assesses the baby’s physical condition at birth.

4.2 Approaches to Childbirth (p. 121)

4.2 Describe natural childbirth and home delivery, noting benefits and concerns associated with each.

In natural, or prepared, childbirth, the expectant mother and a companion typically attend classes where they learn about labor and delivery, master relaxation and breathing techniques to counteract pain, and prepare for coaching during childbirth. Social support from a doula reduces the need for instrument-assisted births and pain medication and is associated with higher Apgar scores.

An upright position and water birth are increasingly popular alternatives that ease labor and delivery for both mother and baby, compared to the traditional lying on the back, feet in stirrups hospital position.

Home birth is safe for healthy mothers assisted by a well-trained doctor or midwife, but mothers at risk for any complication are safer giving birth in a hospital.

4.3 Medical Interventions (p. 123)

4.3 List common medical interventions during childbirth, circumstances that justify their use, and any dangers associated with each.

Fetal monitors help save the lives of many babies at risk for anoxia due to pregnancy complications. Used routinely, however, they may identify infants as in danger who are not, contributing to an increase in instrument and cesarean deliveries.

Use of analgesics and anesthetics to control pain, though sometimes necessary, can prolong labor and compromise newborn adjustment.

Although appropriate when the mother’s pushing is insufficient, instrument delivery can cause serious complications and should be avoided if possible.

Cesarean delivery is warranted for medical emergencies and in some cases of breech position. However, many unnecessary cesareans are performed.

4.4 Birth Complications (p. 126)

4.4a Describe risks associated with oxygen deprivation and with preterm and low-birth-weight infants, along with effective interventions.

Inadequate oxygen supply during labor and delivery can damage the brain, resulting in persisting motor and cognitive deficits that vary in severity with the extent of anoxia. Hypothermia treatment substantially reduces brain damage due to anoxia.

Low birth weight, most common in infants born to poverty-stricken women, is a major cause of neonatal and infant mortality and developmental problems.

Compared with preterm infants, whose weight is appropriate for time spent in the uterus, small-for-date infants usually have longer-lasting difficulties. However, even minimally preterm babies experience greater rates of illness and persisting, mild intellectual delays.

Some interventions for preterm infants provide special stimulation in the intensive care nursery. Others teach parents how to care for and interact with their babies. Preterm infants in stressed, low-income households need long-term, intensive intervention. Skin-to-skin “kangaroo care” promotes survival and diverse aspects of development in preterm infants.

Countries that outrank the United States in infant survival promote prenatal health and effective parenting through government-sponsored high-quality health care and generous, paid employment leave.

4.4b Describe factors that promote resilience in infants who survive a traumatic birth.

When infants experience birth trauma, a supportive family environment or relationships with other caring adults can help restore their growth. Even infants with fairly serious birth complications can recover with the help of positive life events.

4.5 The Newborn Baby’s Capacities (p. 133)

4.5a Describe the newborn baby’s reflexes and states of arousal, including sleep characteristics and ways to soothe a crying baby.

Reflexes are the newborn baby’s most obvious organized patterns of behavior. Some have survival value, others help parents and infants establish gratifying interaction, and still others provide the foundation for voluntary motor skills.

Although newborns move in and out of five states of arousal, they spend most of their time asleep. Sleep includes at least two states: rapid-eye-movement (REM) sleep and non-rapid-eye-movement (NREM) sleep. Newborns spend about 50 percent of their sleep time in REM sleep, far more than they ever will again. REM sleep provides young infants with stimulation essential for central nervous system development. Sleep contributes to babies’ learning and memory.

Disturbed REM–NREM cycles are a sign of central nervous system abnormalities, which may lead to sudden infant death syndrome (SIDS).

A crying baby triggers strong feelings of discomfort in nearby adults. Once feeding and diaper changing have been tried, lifting the baby to the shoulder and rocking or walking is a highly effective soothing technique. Extensive parent–infant physical contact substantially reduces crying in the early months. Support programs can help parents acquire techniques that reduce excessive infant crying.

4.5b Describe the newborn baby’s sensory capacities.

The senses of touch, taste, smell, and sound are well-developed at birth. Newborns use touch to investigate their world, are highly sensitive to pain, prefer sweet tastes and smells, and orient toward the odor of their own mother’s lactating breast and toward human milk rather than formula milk. Attraction to certain flavors, developed through prenatal exposure to a mother’s diet or through breast milk, can, in some instances have long-term consequences for odor and taste preferences.

Newborns can distinguish a variety of sound patterns as well as nearly all speech sounds. They are especially responsive to human speech, high-pitched expressive voices, their own mother’s voice, and speech in their native language.

Vision is the least developed of the newborn’s senses. At birth, focusing ability and visual acuity are limited. Nevertheless, newborns can detect human faces and prefer their mother’s familiar face to the face of a stranger. In exploring the visual field, they are attracted to bright objects but tend to limit their looking to single features. Newborn babies have difficulty discriminating colors.

4.5c Explain the usefulness of neonatal behavioral assessment.

The most widely used instrument for assessing the behavior of newborn infants, Brazelton’s Neonatal Behavioral Assessment Scale (NBAS), has helped researchers understand individual and cultural differences in newborn behavior.

Changes in NBAS scores over the first week or two of life provide the best estimate of the baby’s ability to recover from the stress of birth. Sometimes the NBAS is used to teach parents about their baby’s capacities.

4.6 The Transition to Parenthood (p. 144)

4.6a Discuss the influence of birth-related hormonal changes and parent–infant contact on emergence of parental affection and concern for the infant.

Near birth, mothers—as well as fathers in a warm couple relationship—experience hormonal changes associated with sensitivity and responsiveness to the baby. Although human parents do not require close physical contact with the infant immediately after birth for bonding to occur, hospital practices that promote parent–infant closeness, such as rooming in, may help parents build a good relationship with their newborn.

4.6b Describe changes in the family after the birth of a baby, along with interventions that foster the transition to parenthood.

In response to the demands of new parenthood, the gender roles of parents usually become more traditional. Parents in gratifying marriages who continue to support each other’s needs generally adapt well. But in dual-earner marriages, a large difference between a couple’s caregiving responsibilities can threaten marital satisfaction, especially for women, and negatively affect parent–infant interaction. Favorable adjustment to a second birth typically requires that fathers take an even more active role in parenting.

Early therapeutic intervention can prevent parental depression from interfering with effective caregiving and the parent–child relationship.

Planned births and adoptions by never-married, well-educated women in their thirties and forties have increased dramatically. These mothers typically adapt easily to parenthood. Most nonmarital births are unplanned and to poverty-stricken young women experiencing a stressful transition to parenthood.

When parents are at low risk for problems, counselor-led interventions that focus on strengthening the couple’s relationship and their coparenting skills can ease the transition to parenthood. High-risk parents struggling with poverty or the birth of a baby with disabilities are more likely to benefit from intensive home interventions focusing on enhancing social support and parenting.

IMPORTANT TERMS AND CONCEPTS

anoxia (p. 123)

Apgar Scale (p. 120)

bonding (p. 145)

breech position (p. 125)

cesarean delivery (p. 125)

dilation and effacement of the cervix (p. 119)

fetal monitors (p. 123)

infant mortality (p. 132)

natural, or prepared, childbirth (p. 122)

Neonatal Behavioral Assessment Scale (NBAS) (p. 143)

neonatal mortality (p. 132)

non-rapid-eye-movement (NREM) sleep (p. 137)

preterm infants (p. 128)

rapid-eye-movement (REM) sleep (p. 137)

reflex (p. 133)

rooming in (p. 145)

small-for-date infants (p. 128)

states of arousal (p. 136)

sudden infant death syndrome (SIDS) (p. 138)

transition (p. 119)

visual acuity (p. 143)

Descriptions of Images and Figures

Back to Figure

The process is as follows.

• Stage 1. A, dilation and effacement of the cervix. Contractions of the uterus cause dilation and effacement of the cervix. B, transition. Transition is reached when the frequency and strength of the contractions are at their peak and the cervix opens completely.

• Stage 2. C, pushing. With each contraction, the mother pushes, forcing the baby down the birth canal, and the head appears. D, birth of the baby. Near the end of stage 2, the shoulders emerge, followed quickly by the rest of the baby’s body.

• Stage 3. E, delivery of the placenta. With a few final pushes, the placenta is delivered.

Back to Figure

The data is as follows, with the first number given as the percent discharged alive from hospital and the second the percent with a moderate to severe disability. 23 weeks: 30, 60. 24 weeks: 50, 40. 25 weeks: 60, 15. 26 weeks: 80, 10. 27 weeks: 90, 10. 28 weeks: 90, 10. All values are estimated.

Back to Figure

The graph shows the two groups, the maternal sounds group and the hospital noise group, and the mean standard score thickness of auditory areas for the left and right auditory cortex. The data is as follows.

• Maternal sounds group. Right: 4.1. Left: 7.8.

• Hospital noise group. Right: 2.9. Left: 6.1.

All values are estimated.

Back to Figure

The graph shows the mean change in verbal intelligence scores by the intensity of the intervention for 2 birth weight categories, light birth weight, which is less than 2,001 grams, and heavier birth weight, which is between 2,001 and 2,500 grams. The data is as follows.

• 100 to 300 days, low. Light: negative 2. Heavier: 4.5.

• Greater than 350 days, high. Light: 2, Heavier: 8.

• Greater than 400 days, very high. Light: 8. Heavier: 14.

All values are estimated.

Back to Figure

The number of deaths per 1,000 live births by nation are as follows.

• United States: 5.8

• Bosnia and Herzegovina: 5.3

• Latvia: 5.1

• Slovakia: 5

• Hungary: 4.8

• Canada: 4.5

• Greece: 4.5

• Cuba: 4.4

• New Zealand: 4.4

• Poland: 4.4

• Portugal: 4.3

• Australia: 4.2

• United Kingdom: 4.2

• Denmark: 3.9

• Slovenia: 3.9

• Estonia: 3.8

• Lithuania: 3.7

• Andorra: 3.6

• Ireland: 3.6

• Switzerland: 3.6

• Belarus: 3.6

• Malta: 3.5

• Netherlands: 3.5

• Israel: 3.4

• Austria: 3.3

• Luxembourg: 3.3

• Belgium: 3.3

• Germany: 3.3

• Spain: 3.2

• France: 3.1

• Italy: 3.1

• South Korea: 3

• Czech Republic: 2.7

• Sweden: 2.7

• Finland: 2.5

• Singapore: 2.5

• Norway: 2.5

• Iceland: 2.1

• Japan: 2

Back to Figure

The faces of the babies who are newborns of anise-consuming mothers show mild interest and yawning. The faces of the babies who are newborns of non-anise-consuming mothers show disgust and turning the face away.

Back to Figure

The graph shows the mean ratings by women of mutually supportive caregiving by the time since the baby’s birth in months. The curve labeled relationship-focused intervention rises slightly almost linearly from about 86.5 at 0 months to about 87.5 at 24 months. The curve labeled coparenting-focused intervention starts at about 88 at 0 months, curves up to almost 90 at 12 months, and the falls to about 87 at 24 months. The curve labeled control group starts at about 76 at 0 months and rises through about 78 at 12 months and 82 at 24 months. All values are estimated.