Onset of Vocal Interaction Between Parents and Newborns in Skin‐to‐Skin Contact Immediately After Elective Cesarean Section

Abstract: Background: Cesarean section is associated with delayed mother‐infant interaction because neither the mother nor the father routinely maintains skin‐to‐skin contact with the infant after birth. The aim of the study was to explore and compare parent‐newborn vocal interaction when the infant is placed in skin‐to‐skin contact either with the mother or the father immediately after a planned cesarean section. Methods: A total of 37 healthy infants born to primiparas were randomized to 30 minutes of skin‐to‐skin contact either with fathers or mothers after an initial 5 minutes of skin‐to‐skin contact with the mothers after birth. The newborns’ and parents’ vocal interaction were recorded on a videotape and audiotape. The following variables were explored: newborns’ and parents’ soliciting, newborns’ crying and whining, and parental speech directed to the other parent and to the newborn. Results: Newborns’ soliciting increased over time (p = 0.032). Both fathers and mothers in skin‐to‐skin contact communicated more vocally with the newborn than did fathers (p = 0.003) and mothers (p = 0.009) without skin‐to‐skin contact. Fathers in skin‐to‐skin contact also communicated more with the mother (p = 0.046) and performed more soliciting responses than the control fathers (p = 0.010). Infants in skin‐to‐skin contact with their fathers cried significantly less than those in skin‐to‐skin contact with their mothers (p = 0.002) and shifted to a relaxed state earlier than in skin‐to‐skin contact with mothers (p = 0.029). Conclusions: Skin‐to‐skin contact between infants and parents immediately after planned cesarean section promotes vocal interaction. When placed in skin‐to‐skin contact and exposed to the parents’ speech, the infants initiated communication with soliciting calls with the parents within approximately 15 minutes after birth. These findings give reason to encourage parents to keep the newborn in skin‐to‐skin contact after cesarean section, to support the early onset of the first vocal communication. (BIRTH 37:3 September 2010)     

Maternal Axillar and Breast Temperature After Giving Birth: Effects of Delivery Ward Practices and Relation to Infant Temperature

ABSTRACT: Background: Little is known about the development and control of skin temperature in human mothers after birth. The purpose of this study was to explore the effects of delivery ward practices and early suckling on maternal axillar and breast temperatures during the first 2 hours postpartum and to relate them to the infant’s foot and axillar temperatures. Methods: Three groups of 176 mother‐infant pairs were randomized as follows—group I: infants lying prone in skin‐to‐skin contact on their mother’s chest, named the “skin‐to‐skin group” (n = 44), group II: infants who were dressed and lying prone on their mother’s chest, named the “mother’s arms group” (n = 44), and group III: infants who were dressed and kept in the nursery, named the “nursery group” (n = 88). Maternal axillar and breast temperatures and infants’ axillar and foot temperatures were measured at 15‐minute intervals from 30 to 120 minutes after birth. Episodes of early suckling were noted. Results: The axillar and breast temperatures rose significantly in all mothers. The rise of temperature over time was significantly higher in multiparas than in primiparas but was influenced only slightly by group assignment. The variation in breast temperature was highest in mothers in the skin‐to‐skin group and lowest in mothers in the nursery group. In the mother’s arms group, variation in breast temperature was larger in those mothers exposed to early suckling than in those not exposed. A positive relationship was found between the maternal axillar temperature and the infant foot and axillar temperature 90 minutes after the start of the experiment (120 min after birth) in the skin‐to‐skin and mother’s arms groups. The rise in temperature in the infant’s foot was nearly twice that in the axilla. No such relationship was established in the nursery group. In addition, foot temperature in infants from the skin‐to‐skin group was nearly 2°C higher than that in infants from the mother’s arms group. Conclusions: Maternal temperature rose after birth, and the rise was higher in multiparas than in primiparas. Skin‐to‐skin contact and early suckling increased temperature variation. Maternal temperature was related to infant foot and axillar temperatures. (BIRTH 34:4 December 2007)     

Early Contact versus Separation: Effects on Mother–Infant Interaction One Year Later

Background: A tradition of separation of the mother and baby after birth still persists in many parts of the world, including some parts of Russia, and often is combined with swaddling of the baby. The aim of this study was to evaluate and compare possible long‐term effects on mother‐infant interaction of practices used in the delivery and maternity wards, including practices relating to mother‐infant closeness versus separation. Methods: A total of 176 mother‐infant pairs were randomized into four experimental groups: Group I infants were placed skin‐to‐skin with their mothers after birth, and had rooming‐in while in the maternity ward. Group II infants were dressed and placed in their mothers’ arms after birth, and roomed‐in with their mothers in the maternity ward. Group III infants were kept in the nursery both after birth and while their mothers were in the maternity ward. Group IV infants were kept in the nursery after birth, but roomed‐in with their mothers in the maternity ward. Equal numbers of infants were either swaddled or dressed in baby clothes. Episodes of early suckling in the delivery ward were noted. The mother‐infant interaction was videotaped according to the Parent‐Child Early Relational Assessment (PCERA) 1 year after birth. Results: The practice of skin‐to‐skin contact, early suckling, or both during the first 2 hours after birth when compared with separation between the mothers and their infants positively affected the PCERA variables maternal sensitivity, infant's self‐regulation, and dyadic mutuality and reciprocity at 1 year after birth. The negative effect of a 2‐hour separation after birth was not compensated for by the practice of rooming‐in. These findings support the presence of a period after birth (the early “sensitive period”) during which close contact between mother and infant may induce long‐term positive effect on mother‐infant interaction. In addition, swaddling of the infant was found to decrease the mother’s responsiveness to the infant, her ability for positive affective involvement with the infant, and the mutuality and reciprocity in the dyad. Conclusions: Skin‐to‐skin contact, for 25 to 120 minutes after birth, early suckling, or both positively influenced mother‐infant interaction 1 year later when compared with routines involving separation of mother and infant.     

Maternal Analgesia During Labor Disturbs Newborn Behavior: Effects on Breastfeeding,Temperature, and Crying

Background: Newborns not exposed to analgesia, when placed on the mother's chest, exhibit an inborn prefeeding behavior. This study was performed to assess the effects of different types of analgesia during labor on the development of spontaneous breastfeeding movements, crying behavior, and skin temperature during the first hours of life in healthy term newborns. Methods: Video recordings were made of 28 newborns who had been dried and placed in skin‐to‐skin contact between their mother's breasts immediately after delivery. The video recordings were analyzed blindly with respect to infant exposure to analgesia. Defined infant behaviors were assessed every 30 seconds. Group 1 mothers (n = 10) had received no analgesia during labor, group 2 mothers (n= 6) had received mepivacaine via pudendal block, and group 3 mothers (n= 12) had received pethidine or bupivacaine or more than one type of analgesia during labor. Results: All infants made finger and hand movements, but the infant's massagelike hand movements were less frequent in infants whose mothers had received labor analgesia. A significantly lower proportion of group 3 infants made hand‐to‐mouth movements (p < 0.001), and a significantly lower proportion of the infants in groups 2 and 3 touched the nipple with their hands before suckling (p < 0.01), made licking movements (p < 0.01), and sucked the breast (p < 0.01). Nearly one‐half of the infants, all in groups 2 or 3, did not breastfeed within the first 2.5 hour of life. The infants whose mothers had received analgesia during labor had higher temperatures (p= 0.03) and they cried more (p= 0.05) than infants whose mothers had not received any analgesia. Conclusions: The present data indicate that several types of analgesia given to the mother during labor may interfere with the newborn's spontaneous breast‐seeking and breastfeeding behaviors and increase the newborn's temperature and crying.     

Postpartum Maternal Oxytocin Release by Newborns: Effects of Infant Hand Massage and Sucking

Background: Newborns placed skin‐to‐skin with their mothers show an inborn sequence of behavior similar to that seen in other mammals. The purpose of this study was to make a detailed exploration of hand movements and sucking behavior in healthy term newborns who were placed skin‐to‐skin on their mothers' chests, and to study maternal oxytocin release in relation to these behaviors. Methods: Ten vaginally delivered infants whose mothers had not been exposed to maternal analgesia were video‐recorded from birth until the first breastfeeding. Video protocols were developed based on observations of the videotapes. Each infant's hand, finger, mouth, and tongue movements, positions of the hand and body, and sucking behavior were assessed every 30 seconds. Maternal blood samples were collected every 15 minutes, and oxytocin levels were analyzed by radioimmunoassay. A statistical test for establishing the relationship between maternal oxytocin levels and infants' hand movements or sucking behavior was developed. Results: Infants used their hands to explore and stimulate their mother's breast in preparation for the first breastfeeding. A coordinated pattern of infant hand and sucking movements was also identified. When the infants were sucking, the massagelike hand movements stopped and started again when the infants made a sucking pause. Periods of increased massagelike hand movements or sucking of the mother's breast were followed by an increase in maternal oxytocin levels (p < 0.005). Conclusions: The findings indicate that the newborns use their hands as well as their mouths to stimulate maternal oxytocin release after birth, which may have significance for uterine contraction, milk ejection, and mother‐infant interaction.     

Self‐Rated “No‐” and “Low‐” Risk Pregnancy: A Comparison of Outcomes for Women in Obstetric‐Led and Midwife‐Led Units in England

ABSTRACT: Background: Debate in the United Kingdom about place of birth often concerns obstetric‐led units and midwife‐led units and relates to notions of risk and safety. Outcomes for these two types of unit are often not comparable because of the restricted selection criteria for midwife‐led units. The purpose of this study was to compare outcomes for women intending to give birth in these different types of unit and whose self‐rated pregnancy risk level was “none” or “low.” Methods: Self‐completion questionnaires were distributed to mothers 8 days after the birth in 9 units (6 midwife led 3 obstetric led) over a 6‐month period. Results: Completed questionnaires were received from 432 women (midwife led = 294, obstetric led = 138). Mothers in midwife‐led units spent shorter times in labor in the unit (p < 0.01), received less analgesia (p < 0.01) and had fewer interventions (p < 0.01), and were more likely to have a normal delivery (p < 0.01) than women in obstetric‐led units. Similar differences were found for both primiparous and multiparous women. In terms of the number of midwives attending each woman, analysis of covariance suggested different models of care depending on type of unit (p < 0.05) and parity (p < 0.01). Conclusions: Since these mothers’ self‐rated risk level was none or low, some comparability of outcomes is permissible. It appears that models of care are significantly different in obstetric‐led units compared with midwife‐led units, leading to greater likelihood of intrapartum intervention, need for analgesia, and assisted or operative delivery. A randomized controlled trial examining such units would permit a conclusive examination of these outcomes. (BIRTH 34:4 December 2007)     

Antenatal mother–infant bonding scores are related to maternal reports of infant crying behaviour

Objective: To assess the relation between antenatal mother–infant bonding scores and maternal reports of infant crying behaviour.

Background: Crying is normal behaviour and it is important for parent–infant bonding. Even though bonding starts antenatally, the relation between antenatal bonding scores and infant crying behaviour has never been studied.

Method: A secondary analysis was performed on data that were gathered in a large prospective study within our region. Bonding was assessed using an antenatal bonding questionnaire at 32 weeks gestational age. The crying behaviour of infants was assessed with three questions at six weeks postpartum. Crying was termed excessive (EC+) when mothers perceived the crying to be ‘every day’, ‘often’ or ‘very often’, and with ‘crying episodes lasting more than 30 minutes’; in other words, when mothers scored high on all three questions. The relation between bonding and crying was examined using a multiple logistic regression analysis, including adjustment for relevant variables, especially maternal depression as measured with the Edinburgh Depression Scale.

Results: In total, 894 women were included of whom 47 reported EC+ infants (5.3%). Antenatal bonding scores were significantly related to the reporting of crying behaviour, even after adjustment for relevant variables (p = 0.02). Each extra point on the bonding scale reduced the EC+ risk with 14% (OR = 0.86, 95% CI [0.76–0.97]).

Conclusion: Mothers with lower antenatal bonding scores were more likely to report an EC+ infant. Future research should further explore the concept of antenatal bonding, its relation with EC and risks associated with EC.     

Infant and Neonatal Mortality for Primary Cesarean and Vaginal Births to Women with “No Indicated Risk,” United States, 1998–2001 Birth Cohorts

ABSTRACT: Background: The percentage of United States’ births delivered by cesarean section has increased rapidly in recent years, even for women considered to be at low risk for a cesarean section. The purpose of this paper is to examine infant and neonatal mortality risks associated with primary cesarean section compared with vaginal delivery for singleton full‐term (37–41 weeks’ gestation) women with no indicated medical risks or complications. Methods: National linked birth and infant death data for the 1998–2001 birth cohorts (5,762,037 live births and 11,897 infant deaths) were analyzed to assess the risk of infant and neonatal mortality for women with no indicated risk by method of delivery and cause of death. Multivariable logistic regression was used to model neonatal survival probabilities as a function of delivery method, and sociodemographic and medical risk factors. Results: Neonatal mortality rates were higher among infants delivered by cesarean section (1.77 per 1,000 live births) than for those delivered vaginally (0.62). The magnitude of this difference was reduced only moderately on statistical adjustment for demographic and medical factors, and when deaths due to congenital malformations and events with Apgar scores less than 4 were excluded. The cesarean/vaginal mortality differential was widespread, and not confined to a few causes of death. Conclusions: Understanding the causes of these differentials is important, given the rapid growth in the number of primary cesareans without a reported medical indication. (BIRTH 33:3 September 2006)     

Newborn Temperature During Skin‐to‐Skin Breastfeeding in Couples Having Breastfeeding Difficulties

Abstract: Background: Kangaroo (skin‐to‐skin contact) care facilitates the maintenance of safe temperatures in newborn infants. Concern persists that infants will become cold while breastfeeding, however, especially if in skin‐to‐skin contact with the mother. This concern might be especially realistic for infants experiencing breastfeeding difficulties. The objective was to measure temperature during a study of mothers and infants who were having breastfeeding difficulties during early postpartum and were given opportunities to experience skin‐to‐skin contact during breastfeeding. Method: Forty‐eight full‐term infants were investigated using a pretest‐test‐posttest study design. Temporal artery temperature was measured before, after, and once during 3 consecutive skin‐to‐skin breastfeeding interventions and 1 intervention 24 hours after the first intervention. Results: During skin‐to‐skin contact, most infants reached and maintained temperatures between 36.5 and 37.6 °C, the thermoneutral range, with only rare exceptions. Conclusions: The temperatures of study infants reached and remained at the thermoneutral range during breastfeeding in skin‐to‐skin contact. The data suggest that mothers may have the ability to modulate their infant's temperature during skin‐to‐skin contact if given the opportunity. Hospital staff and parents can be reassured that, with respect to their temperature, healthy newborn infants, with or without breastfeeding difficulties, may safely breastfeed in skin‐to‐skin contact with their mothers. (BIRTH 32:2 June 2005)     

Neonatal Mortality for Primary Cesarean and Vaginal Births to Low‐Risk Women: Application of an “Intention‐to‐Treat” Model

ABSTRACT: Background: The percentage of United States births delivered by cesarean section continues to increase, even for women considered to be at low risk for the procedure. The purpose of this study was to use an “intention‐to‐treat” methodology, as recommended by a National Institutes of Health conference, to examine neonatal mortality risk by method of delivery for low‐risk women. Methods: Low‐risk births were singleton, term (37–41 weeks’ gestation), vertex births, with no reported medical risk factors or placenta previa and with no prior cesarean section. All U.S. live births and infant deaths for the 1999 to 2002 birth cohorts (8,026,415 births and 17,412 infant deaths) were examined. Using the intention‐to‐treat methodology, a “planned vaginal delivery” category was formed by combining vaginal births and cesareans with labor complications or procedures since the original intention in both cases was presumably a vaginal delivery. This group was compared with cesareans with no labor complications or procedures, which is the closest approximation to a “planned cesarean delivery” category possible, given data limitations. Multivariable logistic regression was used to model neonatal mortality as a function of delivery method, adjusting for sociodemographic and medical risk factors. Results: The unadjusted neonatal mortality rate for cesarean deliveries with no labor complications or procedures was 2.4 times that for planned vaginal deliveries. In the most conservative model, the adjusted odds ratio for neonatal mortality was 1.69 (95% CI 1.35–2.11) for cesareans with no labor complications or procedures, compared with planned vaginal deliveries. Conclusions: The finding that cesarean deliveries with no labor complications or procedures remained at a 69 percent higher risk of neonatal mortality than planned vaginal deliveries is important, given the rapid increase in the number of primary cesarean deliveries without a reported medical indication. (BIRTH 35:1 March 2008)     

Validity and reliability of the neonatal skin condition score

OBJECTIVE: To demonstrate the validity and reliability of the Neonatal Skin Condition Scale (NSCS) used in the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) and the National Association of Neonatal Nurses (NANN) neonatal skin care evidence-based practice project. SETTING: NICU and well-baby units in 27 hospitals located throughout the United States. PARTICIPANTS: Site coordinators (N = 27) and neonates (N = 1,006) observed during both the pre and postimplementation phases of the original neonatal skin care project. METHOD: To assess reliability, two consecutive NSCS assessments on a single infant were analyzed. Site coordinators were contacted after the original project was concluded. Sites indicating that a single nurse scored all infant skin observations provided data that were used to evaluate intrarater reliability. Sites using more than one nurse to score skin observations provided data that were used to assess interrater reliability. To assess validity, the following variables were used from the original data set: the Neonatal Skin Condition Scale (NSCS), with three subscales for dryness, erythema, and breakdown; birth weight in grams; number of skin score observations for each infant; and the prevalence of infection, defined as a positive blood culture. RESULTS: For intrarater reliability, 16 sites used a single nurse for all NSCS assessments; total NSCS assessments 475. For interrater reliability, 11 sites used multiple raters; total assessments 531. The NSCS demonstrated adequate reliability for each of the three subscales and for the total score, with the percent agreement between scores ranging from 68.7% to 85.4% (intrarater) and 65.9% to 89% (interrater); all Kappas were significant at p < .001 and were in the moderate range for reliability. The validity of the NSCS was demonstrated by the findings that smaller infants were 6 times more likely to have erythema (chi2(6) = 109.55, p < .0001), and approximately twice as likely to have the most severe breakdown (chi2(6) = 108.01, p < .0001). Infants with more observations (longer length of stay) had higher skin scores (odds ratio = 1.21, p < .0001), and an increased probability of infection was noted for infants with higher skin scores (odds ratio = 2.25, p < .0001). CONCLUSIONS: The Neonatal Skin Condition Score (NSCS) is reliable when used by single and multiple raters to assess neonatal skin condition, even across weight groups and racial groups. Validity of the NSCS was demonstrated by confirmation of the relationship of the skin condition scores with birth weight, number of observations, and prevalence of infection.     

Baby please stop crying: an experimental approach to infant crying,affect, and expected parenting self-efficacy

Objective: The present study examines the effect of infant crying on parental affect, state anxiety and parenting self-efficacy in an experimental setting. Background: Infant crying causes distress and feelings of incompetence in many parents. These frustrating parental feelings can lead to suboptimal caregiving behaviour or even child abuse. Studies focusing on the effects of infant crying experience causality issues, as parental behaviour can also increase infant crying. Methods: One hundred and sixteen students of Tilburg University were asked to babysit a life-like crying doll for 10 minutes. Participants were exposed to either no crying, 5 minutes of crying, or 10 minutes of crying. Results: Participants in the crying conditions experienced more negative affect, state anxiety, and felt less confident about their ability to parent in the future. Conclusion: These findings have implications for the parents of newborn babies who experience distress and feelings of incompetence caused by infant crying.     

Prematurity stereotyping and perceived vulnerability at 5‐months: Relations with mothers and their premature and full‐term infants at 9‐months

Objective: To examine the relationship between mothers' prematurity stereotyping and perceptions of vulnerability at 5 months and mother–infant interactions at 9 months for mothers of premature (N = 56) and full‐term (N = 59) infants. Method: At 5 months, mothers rated videotapes of unfamiliar infants given either a full‐term label (FTL) or premature label (PL) and completed questionnaires. At 9 months, mothers were videotaped in interactions with their own infant. A subgroup of mothers completed questionnaires at 32 months. Results: Mothers who more positively rated infants labelled with the same birth status as their own infants chose a more mature toy for their own infant and exhibited more positive interactive behaviours with their own infant at 9 months. Mothers who viewed their infant as more vulnerable at 5 months demonstrated less positive interactions with their 9‐month old infants. Both mothers of premature and full‐term infants who rated FTL infants more positively at 5 months felt less self‐efficacious; however, the former group felt more overprotective whereas the latter group reported less overprotectiveness. Conclusions: Results show some support for a relationship between early maternal cognitions and later maternal behaviour, although present findings are not as consistent as in previous studies. Implications of these findings are discussed.     

Continuity of Nursing Care and Its Link to Cesarean Birth Rate

ABSTRACT: Background: High cesarean birth rates are an international concern. The role of patterns of nursing care responsibility in preventing or contributing to cesarean births has been understudied. Our study sought to identify and describe indicators of continuity of nursing care responsibility during labor and to explore whether any association between these indicators and risk of cesarean birth could be identified empirically using an existing data set. Methods: We obtained a representative sample of low‐risk women giving birth in an intrapartum unit at a university hospital in Quebec, Canada, with approximately 3,700 births per year. To be considered for inclusion, women needed to have been primiparous, carrying singletons in vertex position, and at 37 weeks’ gestation or more. All women giving birth over a 13‐month period were assessed for eligibility using the hospital’s birth log. Data were extracted from the medical records of every second eligible birth, including information related to patterns of nursing care responsibility, maternal and infant characteristics, obstetric procedures, non–health‐related risk factors, and type of birth. Results: Data on all variables of interest were available for 467 women. These women were cared for by 1–17 nurses, care responsibility changed hands for them from 1 to 28 times, and the mean length of labor for which the same nurse was responsible for a woman ranged from 10 to 1,045 minutes. After controlling for length of labor, maternal age, maternal height, infant weight, gestational age, induction, type of rupture, and epidural analgesia, the odds ratio for cesarean birth due to number of nurses was 1.17 (95% CI 1.04, 1.32); 1 or more nurses switch per 2 hours (i.e., number of times care responsibilities changed hands), 1.04 (95% CI 0.62, 1.74); and 33 percent or more of the labor attended by the same nurse, 0.74 (95% CI 0.42, 1.30). Conclusions: An association was observed between number of nurses caring for a laboring woman and risk of cesarean delivery. Estimates of the association of other patterns of nursing care responsibility on cesarean birth were not sufficiently precise to draw conclusions. (BIRTH 34:1 March 2007)     

The Relationship of Maternal Personality Characteristics to Birth Outcomes and Infant Development

Background: Previous studies reported an association between maternal psychological factors and adverse pregnancy outcomes. The objective of this study was to evaluate the relationships between maternal personality characteristics, as determined by the Minnesota Multiphasic Personality Inventory (MMPI), and infant birth outcomes and development. Method: The inventory was administered during pregnancy to 638 pregnant women enrolled in a staff model health maintenance organization. MMPI validity as well as clinical and research scales were evaluated in relationship to infant birth outcomes (low birthweight, preterm birth) and 15‐month‐old infant development as assessed by the Bayley Scales of Infant Development. Results: Mothers of low birthweight infants scored significantly lower on the hypochondriasis scale, a relationship which was no longer significant after controlling for ethnicity. No other relationships were observed between infant birth outcomes and maternal MMPI scale scores. A higher infant Mental Developmental Index (MDI) was related to higher maternal masculinity‐femininity and ego‐strength scale scores and lower lie and hypochondriasis scale scores. Only the relationship between infant MDI and maternal masculinity‐femininity scale score remained significant after controlling for ethnicity and socioeconomic index (β= 0.104, p =0.036). Conclusions: Maternal personality characteristics, as determined by the MMPI, did not appear to be significantly related to the occurrence of preterm birth or low birthweight in this healthy, general population. Maternal personality characteristics reflected in the MMPI masculinity‐femininity scale appeared to be related to infant mental development, above and beyond the effects of socioeconomic status and ethnicity.     

Live Music Is Beneficial to Preterm Infants in the Neonatal Intensive Care Unit Environment

Abstract: Background: Music stimulation has been shown to provide significant benefits to preterm infants. We hypothesized that live music therapy was more beneficial than recorded music and might improve physiological and behavioral parameters of stable preterm infants in the neonatal intensive care unit. Methods: Thirty‐one stable infants randomly received live music, recorded music, and no music therapy over 3 consecutive days. A control of the environment noise level was imposed. Each therapy was delivered for 30 minutes. Inclusion criteria were postconceptional age ≥ 32 weeks, weight ≥ 1,500 g, hearing confirmed by distortion product otoacoustic emissions (DPOAEs), and no active illness or documentation of hyperresponsiveness to the music. Heart rate, respiratory rate, oxygen saturation, and a behavioral assessment were recorded, every 5 minutes, before, during, and after therapy, allowing 30 minutes for each interval. The infant's state was given a numerical score as follows: 1, deep sleep; 2, light sleep; 3, drowsy; 4, quiet awake or alert; 5, actively awake and aroused; 6, highly aroused, upset, or crying; and 7, prolonged respiratory pause > 8 seconds. The volume range of both music therapies was from 55 to 70 dB. Parents and medical personnel completed a brief questionnaire indicating the effect of the three therapies. Results: Live music therapy had no significant effect on physiological and behavioral parameters during the 30‐minute therapy; however, at the 30‐minute interval after the therapy ended, it significantly reduced heart rate (150 ± 3.3 beats/min before therapy vs 127 ± 6.5 beats/min after therapy) and improved the behavioral score (3.1 ± 0.8 before therapy vs 1.3 ± 0.6 after therapy, p < 0.001). Recorded music and no music therapies had no significant effect on any of the tested parameters during all intervals. Both medical personnel and parents preferred live music therapy to recorded music and no music therapies; however, parents considered live music therapy significantly more effective than the other therapies. Conclusions: Compared with recorded music or no music therapy, live music therapy is associated with a reduced heart rate and a deeper sleep at 30 minutes after therapy in stable preterm infants. Both recorded and no music therapies had no significant effect on the tested physiological and behavioral parameters. (BIRTH 33:2 June 2006)     

Breastfeeding Rates and Hospital Breastfeeding Practices in Canada: A National Survey of Women

Background: The Baby‐Friendly Hospital Initiative was launched by the World Health Organization and UNICEF in 1989 to promote, protect, and support breastfeeding worldwide. The objective of this study was to report breastfeeding rates and adherence to the Baby Friendly Hospital Initiative of the World Health Organization and UNICEF in Canada, as reported by participants in the Maternity Experiences Survey of the Canadian Perinatal Surveillance System. Methods: Eligible women (n = 8,244) were identified from a randomly selected sample of infants born 3 months before the May 2006 Canadian Census, and stratified by province or territory. Birth mothers living with their infants at the time of interview were invited to participate in a computer‐assisted telephone interview conducted by Statistics Canada on behalf of the Public Health Agency of Canada. Interviews took approximately 45 minutes and were completed when infants were between 5 and 10 months old (between 9 and 14 months in the territories). Completed responses were obtained from 6,421 women (78% response rate). Nineteen of 309 questions concerned early mother‐infant contact and breastfeeding practices. Results: Breastfeeding intention (90.0%) and initiation (90.3%) rates were high, although exclusive breastfeeding rates at 6 months after birth (14.4%) were lower than desirable. The findings suggested a low adherence to several best practices advocated by the Baby‐Friendly Hospital Initiative. Conclusion: Although breastfeeding initiation rates were relatively high in Canada, exclusive breastfeeding duration fell short of globally recommended standards.     

Quality of Life of Caregivers of Very Low–Birthweight Infants

ABSTRACT: Background: The health and developmental outcomes of very low–birthweight infants are unpredictable over the first year of life. This uncertainty may have meaningful consequences for parents’ quality of life. The objective of this study was to explore the quality of life of caregivers of these infants. Methods: Primary caregivers of very low–birthweight infants, 12 to 18 months old, who had been cared for in an inner‐city hospital were enrolled in the study. Primary caregivers of full‐term infants of the same age served as a comparison group. During a telephone survey, participants answered questions about their quality of life, mental and physical health, living arrangements, and child’s health. Results: Eighty‐three caregivers of very low–birthweight infants and 84 caregivers of full‐term infants were enrolled in the study. Demographic characteristics of the caregivers were similar between the groups. Forty‐five percent of caregivers of very low–birthweight infants reported that their child had an ongoing medical problem compared with 23 percent of caregivers of full‐term infants. Both groups of caregivers reported significant physical and mental health problems. Caregivers of very low–birthweight infants reported higher quality of life than did caregivers of full‐term infants, but the difference did not reach statistical significance. Conclusions: Although very low–birthweight infants had poorer health and required significantly more health care resources than full‐term infants, caregivers’ quality of life did not differ between the two groups. Caregivers of both groups of infants reported substantial mental and physical health problems but perceived good quality of life. These data will aid parents, physicians, and policy makers as they struggle to make decisions concerning care of high‐risk, costly, very low–birthweight infants. (BIRTH 35:3 September 2008)     

Making Choices for Childbirth: A Randomized Controlled Trial of a Decision‐aid for Informed Birth after Cesareana

ABSTRACT: Background: Decision‐making about mode of birth after a cesarean delivery presents challenges to women and their caregivers and requires a balance of risks and benefits according to individual circumstances. The study objective was to determine whether a decision‐aid for women who have experienced previous cesarean birth facilitates informed decision‐making about birth options during a subsequent pregnancy. Method: A prospective multicenter randomized controlled trial of 227 pregnant women was conducted within 3 prenatal clinics and 3 private obstetric practices in New South Wales, Australia. Women with 1 previous cesarean section and medically eligible for trial of vaginal birth were recruited at 12 to 18 weeks’ gestation; 115 were randomized to the intervention group and 112 to the control group. A decision‐aid booklet describing risks and benefits of elective repeat cesarean section and trial of labor was given to intervention group women at 28 weeks’ gestation. Main outcome measures included level of knowledge, decisional conflict score, women's preference for mode of birth, and recorded mode of birth. Results: Women who received the decision‐aid demonstrated a significantly greater increase in mean knowledge scores than the control group (increasing by 2.17 vs 0.42 points on a 15‐point scale)(p < 0.001, 95% CI for difference = 1.15–2.35). The intervention group demonstrated a reduction in decisional conflict score (p < 0.05). The decision‐aid did not significantly affect the rate of uptake of trial of labor or elective repeat cesarean section. Preferences expressed at 36 weeks were not consistent with actual birth outcomes for many women. Conclusion: A decision‐aid for women facing choices about birth after cesarean section is effective in improving knowledge and reducing decisional conflict. However, little evide nce suggested that this process led to an informed choice. Strategies are required to better equip organizations and practitioners to empower women so that they can translate informed preferences into practice. Further work needs to examine ways to enhance women's power in decision‐making within the doctor‐patient relationship. (BIRTH 32:4 December 2005)