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MATERNAL PERINATAL BEHAVIOUR. Dr Nils Bergman ”M.D., D.C.H., M.P.H., Ph.D.” M.B.Ch.B., M.P.H., M.D. ”M.D., D.C.H., M.P.H., Ph.D.” M.B.Ch.B., M.P.H., M.D.

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Presentation on theme: "MATERNAL PERINATAL BEHAVIOUR. Dr Nils Bergman ”M.D., D.C.H., M.P.H., Ph.D.” M.B.Ch.B., M.P.H., M.D. ”M.D., D.C.H., M.P.H., Ph.D.” M.B.Ch.B., M.P.H., M.D."— Presentation transcript:

1 MATERNAL PERINATAL BEHAVIOUR. Dr Nils Bergman ”M.D., D.C.H., M.P.H., Ph.D.” M.B.Ch.B., M.P.H., M.D. ”M.D., D.C.H., M.P.H., Ph.D.” M.B.Ch.B., M.P.H., M.D. Cape Town, South Africa

2 Speaker Disclosure Under ACCME guidelines: a) I have a financial affiliation with AMEDA : Speakers Bureau b) My wife markets educational materials and shirts related to the talk content Kangaroo Mother Care Promotions

3 PERINATOLOGY !!! Neonatal care = postpartum OBGYN Neonatal outcomes may be predetermined at birth... neonatal care should start at conception !!!!

4 Doula care “ doula ” -- Greek word for a “ birth companion ” In 127 out of 128 societies (reported in a major anthropological study of non-industrialised geographically isolated societies) “ a woman is in attendance throughout labour ” not the father …. not a midwife !!

5 Effects of doula care No doula Doula USA (Kennell et al 1991) Epidural55%8% Caesarean section18%8% Forceps delivery26%8% Fetal distress24%10%

6 Effects of doula care No doula Doula USA (Kennell et al 1991) Caesarean section18%8% Cost of C/S = R3600 at MMH. Cost of NVD = R1800 at MMH Halved C/S rate would save = R2.2 m A doula for every delivery = R1.6 m Add epidural saving, less fetal distress …

7 Active Birth. Active birth is NOT - providing a place - with amenities - alternative or complementary care - abdicating clinical responsibility

8 Active Birth … … enables a labouring woman to respond naturally and instinctively to her birthing process, and to make appropriate choices. Women are encouraged to remain mobile and upright and to adopt the position of their choice during labour and birth, and unnecessary restrictions and procedures are minimized. Fundamentally it is an attitude of respect and support for the labouring woman and her family. (Adopted by ABU Board, 28 August 2002)

9 Active Birth. Active Birth is about allowing the mother to be in tune with herself and her pregnancy, to empower her and give her control of her own labour. Active Birth provides time and space for the family to bond and grow.

10 ANNA ANNA “I lost it”... Unpleasant.... Surrender to process These experiences are embedded in the attachment relationship.

11 Active Birth. Fundamentally, it returns respect and dignity to the mother.

12 Birthing position 1000 year old Mexican statue of woman in labour, was exhibited in Denmark for 20 years, lying down. Same Mexican statue, placed vertically -toes curl appropriately, -leaves do not fall off her shoulders - headpiece undisturbed

13 Birthing position In 80% of societies, mothers deliver in upright position, which increases the pelvic outlet diameter by 28% Duration of labour is reduced by %

14 Birthing position Mothers in Active Birth will “instinctively” choose birth positions appropriate to the lie and presentation of the fetus. Squatting, kneeling, lying, crouching … There is only one bad position =lithotomy

15 INCREASED BRAIN SIZE TOOL USE &LANGUAGE BIPEDALISM & NARROWERPELVIS … PROBLEM ? … PROBLEM ? How is the bigger head going to be head going to be born out of the born out of the smaller pelvis ?? smaller pelvis ??

16 INCREASED BRAIN SIZE BIPEDALISM & NARROWERPELVIS EXCEEDINGLYIMMATUREBIRTH The growing brain must come out must come out before it is too before it is too big to pass big to pass through through the birth canal... the birth canal...

17 SOLUTION: “the birth of exceedingly neurologically immature infants for whom the majority of brain growth will occur postnatally and not in the womb.” (McKenna 1993)

18 100% 25% 0% CONCEPTION FETUS 80%

19 100% 25% 0% ADULTBIRTH CONCEPTION FETUSNEWBORN In all mammals, In all mammals, brain grows in brain grows in utero until it utero until it reaches 80% of reaches 80% of full adult size …. full adult size …. … then BIRTH … then BIRTH … then the brain grows the last grows the last 20% to final 20% to final full adult size. full adult size. 80%

20 100% 25% 0% Homo sapiens Homo sapiens = HUMAN also has a brain also has a brain that grows along that grows along this pattern … this pattern … … the brain … the brain reaches 80% reaches 80% of final size of final size at the age of at the age of 21 months 21 months EXPECTEDBIRTH 21/12

21 100% 25% 0% Actual birth takes place at takes place at 9 months … … which makes … which makes the human birth the human birth one year too soon: one year too soon:EXCEEDINGLYIMMATURE EXPECTEDBIRTH 21/12 ACTUALBIRTH 9/12

22 100% 25% 0% Humansessentially complete complete gestation gestation OUTSIDE OUTSIDE THE WOMB. THE WOMB. EXPECTEDBIRTH 21/12 ACTUALBIRTH 9/12

23 100% 25% 0% A fullterm newborn has 12 months of gestation to complete ! EXPECTEDBIRTH 21/12 ACTUALBIRTH 9/12

24 Maternal behavior among primates extends throughout an extremely long infant and juvenile period, with prolonged periods of physical contact. (Orangutan) At birth the human infant is the least neurologically mature primate of all, and the most reliant on physiological regulation b the caregiver for the longest period of time. (McKenna)

25 QUESTION ? HOW SAFE IS THIS? DOULA, ACTIVE BIRTH

26 “SOLUTION: “the birth of exceedingly neurologically immature infants for whom the majority of brain growth will occur postnatally and not in the womb.” (McKenna 1993) THIS WAS A COMPROMISE …

27 THE PRICE FOR MOTHERS: Cephalopelvic disproportion. Cephalopelvic disproportion. Maternal mortality risk. THE PRICE FOR NEWBORNS: Biological immaturity comes at the increased risk for PREMATURITY, PREMATURITY, Hyaline membrane disease

28 CONSEQUENCE “Back to nature” is NOT recommended ! Understanding nature is essential …. Care should be based on this understanding: Antenatal care, Emotional support  clinical effects NO SEPARATION of dyad.

29 THE GAINS Intelligence drive – positive feedback loop: Greater mother’s intelligence required to care for baby …. Mother chooses man accordingly immature baby drives IQ increase

30 Doula care, Active Birth, and the Birth positions described have evolutionary and neurobehavioural origins, evidenced in anthropological studies, which minimise the very high risk of adverse outcome from CPD. ( Equates to better care at lower cost )

31 PERINATOLOGY !!! – OBGYN care = antepartum neonatology “practice strategies to promote dyad care” R.D. White 2004 (p 384)

32 PERINATOLOGY !!! Neonatal care = postpartum OBGYN “ The parents body can be seen as the most optimal, appropriate and physiologically stabilising environment for these infants ” J.V. Browne 2004 (p294)

33 IN ALL MAMMALS : The brain events originate in the old mammalian brain - “innate programmed behaviour”

34 THE HINDBRAIN HAS 3 PROGRAMMES DEFENSENUTRITIONREPRODUCTION

35 The neurobehavioural programme is situated in the hind brain, limbic system hypothalamus (autonomic nervous system) hypophysis (endocrine system, hormones)

36 DEFENSENUTRITIONREPRODUCTION HORMONES NERVESMUSCLES

37 ONLY ONE PROGRAM is ever operating at any one time – usually it is NUTRITION DEFENSENUTRITIONREPRODUCTION HORMONES NERVESMUSCLES

38 REPRODUCTIONNUTRITION The DEFENCE program shuts off the others immediately off the others immediately HORMONES NERVESMUSCLES DEFENSE

39 All 3 programs work on same systems, only purpose differs HORMONES NERVESMUSCLES DEFENSENUTRITIONREPRODUCTION

40 The hormones, nerves, muscles drive entire system or body HORMONES NERVESMUSCLES BODY

41 The result of all this is BEHAVIOUR HORMONES NERVESMUSCLES BODY

42 The reproductive programme is in the mother and the baby HORMONES NERVESMUSCLES DEFENSENUTRITIONREPRODUCTION

43

44 Estrogen peaks Progesterone falls Increased spines (dendrification) New circuits = enhanced learning Pup stimulation Rich environment

45 New circuits = enhanced learning Less fear / anxiety Amygdala Better learning / memory Hippocampus Better stress tolerance Hypothalamus Maternal neurobehaviour

46 Enhanced foraging More emotional resilience Stress responsiveness Enhanced problem solving

47 Enhanced foraging Enhanced problem solving

48 Moreemotionalresilience Stress responsiveness

49 PROLACTION rises OXYTOCIN rises MEMORY permanently improved BDNF (=Brain Derived Neurotropic Factor) Opioids Glucocorticoids etcetera..... Norepinephrine Vasopressin(fathers specially) LACTATION

50 MEMORY permanently improved

51 BDNF (=Brain Derived Neurotropic Factor) “ The picture that begins to emerge is one of a healthy, “ protected ” brain that may provide benefits to its owner well into senescence. ” (p517)

52 “ the totality and natural ramifications of reproductive experience.... enhancements.... neuroplasticity... (p522) (p522) “ The combination of these... converge to produce the most dramatic results...

53 The reproductive programme is in the mother and the baby WHAT IS NORMAL MOTHER BEHAVIOUR? DEFENSENUTRITIONREPRODUCTION

54 How many mothers in this room have breastfed their babies? How many mothers in this room had babies that breastfed?

55 BREASTFEEDING IS A BRAIN BASED BEHAVIOUR

56 THE NEWBORN INITITIATES BREASTFEEDING

57 THE NEWBORN MAINTAINS BREASTFEEDING

58 BREASTFEEDING IS A BEHAVIOUR OF THE NEWBORN Not the mother !!

59 IN ALL MAMMALS : The brain events originate in the hindbrain

60 THE HINDBRAIN HAS 3 PROGRAMMES DEFENSENUTRITIONREPRODUCTION

61 All 3 programs work on same systems, only purpose differs HORMONES NERVESMUSCLES DEFENSENUTRITIONREPRODUCTION

62 The result of all this is BEHAVIOUR HORMONES NERVESMUSCLES BODY

63 WHAT IS APPROPRIATE BEHAVIOUR OF THE MOTHER ?

64 “ …. mother to hold and care for her baby”

65 Mother’s have an innate, inborn BEHAVIOUR HORMONES NERVESMUSCLES HOLD & CARE

66 50 million years – PRIMATES PRIMATES Primates carry their young, due to their relative immaturity.

67 40 million years – PRIMATES PRIMATES Newborn apes have a powerful grasp reflex, due to quadrupedal gait. They are “carry feeders” And they feed “continuously”

68 4 million years – HOMINIDS HOMINIDS Newborn Homo weak grasp reflex, due to bipedal, hairless mother They have to be “HOLD feeders”

69 40 million years – primates primates Newborn apes powerful grasp reflex, due to quadrupedal They are “carry feeders” 4 million years – HOMINIDS HOMINIDS Newborn Homo weak grasp reflex, due to bipedal, hairless mother They have to be “HOLD feeders”

70 4 million years – HOMINIDS HOMINIDS Newborn Homo weak grasp reflex, due to bipedal, hairless mother They have to be “HOLD feeders”

71 Hold and carry This holding is the best for a baby, but it is also deeply fulfilling for a mother. (Jill Bergman, 2007)

72 100% 25% 0% Actual birth takes place at takes place at 9 months … … which makes … which makes the human birth the human birth one year too soon: one year too soon:EXCEEDINGLYIMMATURE EXPECTEDBIRTH 21/12 ACTUALBIRTH 9/12

73 The human baby is born with only 25% of its final brain size; if it followed the pattern of other mammals, humans should be born at 21 months! They need to be held and carried for the first two years of life for optimal brain development

74 MOTHER MOTHER is the KEY for NEURODEVELOPMENT

75 Mother is PRIMARY CAREGIVER Nurse is PRIMARY SUPPORTER Empowerment & ownership

76 Empower the parents to care for their own baby.Empower the parents to care for their own baby. Nurse is to encourage and reassureNurse is to encourage and reassure For the nurse it is weeks, for Mum and baby it is the start of their whole lives!For the nurse it is weeks, for Mum and baby it is the start of their whole lives! Explain what is happeningExplain what is happening

77 BREAST-VAGAL MOTHER FEEDING(PSNS) GROWTH OTHERPROTEST-STRESSSURVIVAL or DESPAIR(SNS) SKIN-TO-SKIN CONTACT SEPARATION PLACE MODEL THE PLACE MODEL

78 BREAST-VAGAL MOTHER FEEDING(PSNS) GROWTH OTHERPROTEST-STRESSSURVIVAL or DESPAIR(SNS) SKIN-TO-SKIN CONTACT SEPARATION

79 HYPERAROUSAL - (Schore 2001) distress crying... then screaming, then “fear-terror” distress crying... then screaming, then “fear-terror”

80 FETALCIRCULATION (from J Lind et al ) (from J Lind et al ) Oxygen rich blood from placenta, First through liver, to inf vena cava, Divides in heart, through FORAMEN OVALE Right flow to brain Left flow to body, AND back to placenta PLACENTA BRAIN LUNG LIVER RV LV LA RA

81 NEONATAL CIRCULATION (from J Lind et al ) (from J Lind et al ) Expansion of lungs (takes one third second,) Pushes volume of fluid to left ventricle, pressure CLOSES foramen ovale Left ventricle pushes blood to brain and body Blood returns via both vena cava, Right heart pumps to LUNGS, Oxygenated blood to left heart Left atrial pressure keeps foramen ovale closed. PLACENTA BRAIN LUNG LIVER

82 NEONATAL CIRCULATION (from J Lind et al ) (from J Lind et al ) There is a small amount of contrast shunted to LA. contrast shunted to LA. Note also that contrast refluxes easily up into the easily up into the superior vena cava

83 CRYINGCIRCULATION (from J Lind et al ) CRYING INCREASES right atrial pressure closed glottis Thoracic contraction Abdominal muscles BRAIN LUNG LIVER

84 CRYING CIRCULATION (from J Lind et al ) (from J Lind et al ) CRYING INCREASES right atrial pressure The foramen ovale OPENS, Venous blood mixes with oxygenated blood, Cyanosis results

85 CRYING CIRCULATION (from J Lind et al ) (from J Lind et al ) CRYING INCREASES right atrial pressure Foramen ovale OPENS Venous blood mixes with oxygenated blood, Cyanosis results ALSO: increased pressure in carotid arteries increased pressure in superior vena cava Choroid plexus unsupported Intraventricular haemorrhage BRAIN LUNG LIVER

86 “Crying, the highest behavioural state, is DETRIMENTAL. It impairs lung functioning, jeopardizes the closure of the foramen ovale, increases intra-cranial pressure, and initiates a cascade of stress reactions”. (Anderson 1996)

87 “Crying, the highest behavioural state, is DETRIMENTAL. Separated infants cry much more SSC babies Cot babies Number of cries441 Seconds cried (Christenson 1992)

88 CRYING IS BAD FOR BABY !! “ Crying … depletes energy reserves and oxygen, increases intracranial pressure, increases white blood count and increases base excess, re-establishes fetal circulation, interferes with the infant ’ s ability to interact with caregivers.” Gene Cranston Anderson (1984)

89 CRYING IS BAD FOR BABY !! “These effects place fullterm and preterm infants at greater risk for respiratory distress, pneumothorax, acute or subclinical intra-ventricular haemorrhage, unnecessary treatment for pseudosepsis, delayed circulatory and psychosocial adaptation to extrauterine life. ” Gene Cranston Anderson (1984)

90 CRYING IS BAD FOR BABY !! These effects place fullterm and preterm infants at greater risk for delayed physiological and psychosocial adaptation to extrauterine life. ” Gene Cranston Anderson (1984)

91 HYPERAROUSAL - (Schore 2001) distress crying... then distress crying... then (neurologically) compelled to approach maintains proximity and elicits care

92 Children Need Touching and Attention, Harvard Researchers Say April 09, 1998 America's "let them cry" attitude toward children may lead to more fears and tears among adults, according to two Harvard researchers. Instead of letting infants cry, American parents should keep their babies close, console them when they cry, and bring them to bed with them, where they'll feel safe, according to Michael Commons and Patrice Miller

93 BABIES SHOULD NEVER CRY

94 efficiently regulated and organised right brain AMYGDALA: fear and emotion fear and emotion Prefrontal cortex approach / avoid approach / avoid Behavioural activation system reward-based (dopamine) (dopamine) Amodio 2008

95 MATERNAL-INFANTSEPARATION = ABUSE

96 “Society reaps what it sows in the way that infants and children are treated. Efforts to reduce exposure to stress and abuse in early life may have far-reaching impacts on medical and psychiatric health and may reduce aggression, suspicion and untoward stress in future generations.” Martin H Teicher

97 “Society reaps what it sows in the way that infants and children are treated. Efforts to reduce exposure to stress and abuse (specifically MATERNAL INFANT SEPARATION Bergman ) in early life may have far-reaching impacts on medical and psychiatric health and may reduce aggression, suspicion and untoward stress in future generations.” Martin H Teicher

98 In the FIRST HOUR ……. ….. the newborn ELICITS CARE GIVING INSTINCTUAL BEHAVIOUR FROM THE MOTHER !!

99 Measure of a “good mammal mother” : FEROCITY OF DEFENCE OF YOUNG. Oxytocin effect !!!!

100 Margaret Mikol TIME Magazine, June 4, Margaret Mikol “I changed into a beast to protect my child”

101 Measure of a “good mammal mother” : FEROCITY OF DEFENCE OF YOUNG. Oxytocin effect !!!!

102 Measure of a “good mammal mother” : FEROCITY OF DEFENCE OF YOUNG. Sodersjukhuset, Stockholm Randomisation to new and old unit

103 Maternal ferocity ??? Replaced by subservient inheritance ! thankfulness, staff “own the baby” bonding & attachment breastfeeding success ?

104 Separation causes changes in the fundamental efficiency of systems … (McKenna 1993)

105 THE “PRIMARY VIOLATION” … the very worst thing … to any newborn according to biologists is SEPARATION. SEPARATION !!!

106 to any newborn according to biologists is SEPARATION. TO ANY MOTHER DISEMPOWERMENT !!! SEPARATION !!!

107 Maternal effects of separation – Lack of bonding Postnatal depression Breast problems –

108 Birth/NICU  KMC ward  Discharge PPD37.3%16.9% PPD = Post Partum Depression

109 Dombrowski et al ABSTRACT The mother in this case study had numerous known risk factors for PPD. expressing feelings of sadness baby unwrapped for first KC. Thereafter her self-reported depression scores decreased rapidly and had disappeared by 32 hours postbirth. had disappeared by 32 hours postbirth. Kangaroo (Skin-to-Skin) Care With a Postpartum Woman Who Felt Depressed

110 There is new knowledge... the maternal HPA axis dampened during last trimester... last trimester... “Perhaps appropriate reactivation of the maternal HPA axis can be triggered following birth by the stimulation inherent in KC, thereby minimizing risk for postpartum depression.

111 MOTHERING DENIED How our culture harms women, infants and society Dr Peter Cook

112 ‘MOTHERING’ = politically incorrect terminology... (parenting, care-giving) culturally not valued.... BUT neuroscience provides new understanding and definitions.. biologically based survival requirement 

113 ‘MOTHERING’ = biological definition breastfeedingcarrying secure attachment mutual reward enjoyment and empathy enjoyment and empathy mutual playfulness and joy ALL have evidence based science

114 ‘MOTHERING’ = biological definition basic needs of infants arise from their biology Mothering is biology

115 ‘MOTHERING’... we can aim to bring our society, that we can change, into better harmony with our biological “givens” that we cannot change...

116 THE HUNTER GATHERER Homo sapiens evolved as a “tropical hunter gatherer”. Anthropological studies of current tropical societies: 20% of diet from hunting mammals, 40-60% from gathering foods Both hunting and gathering require mobility.

117 THE HUNTER GATHERER (cont) Infant care patterns in such societies (which are closest to our origins): 1Infant carried most of time 2Mother sleeps with infant same bed 3Immediate feeding response to crying 4Breastfeeding 24 months or more 5Father frequently and closely involved...

118 Infant care patterns in 186 non-western cultures: newborn is carried constantly, always sleeps with mother immediate feeding if crying feeding on demand, every hour or two breastfeeding for 24 months ( Lozoff and Brittenham, J Pediatrics 1979; 95:478 )

119 ANTHROPOLOGY, HABITAT AND NICHE In a major anthropological study of non-industrialised, geographically isolated societies, : the newborn infant is carried constantly the infant always sleeps with the mother ( Lozoff and Brittenham 1979 )

120 “For species such as primates, the mother IS the environment.” Sarah Blaffer Hrdy, Mother Nature (1999) Babies Celebrated, Beatrice Fontanel and Claire D’Harcourt, © 1998 Harry N. Abrams, Inc. Nothing an infant can or cannot do makes sense, except in light of mother’s body

121 BREAST-VAGAL MOTHER FEEDING(PSNS) GROWTH OTHERPROTEST-STRESSSURVIVAL or DESPAIR(SNS) SKIN-TO-SKIN CONTACT SEPARATION PLACE MODEL THE PLACE MODEL

122 THE HUNTER GATHERER In a major anthropological study of non-industrialised, geographically isolated societies, : the newborn infant is carried constantly the infant always sleeps with the mother PLACE immediate nurturant response to crying feeding on demand, every hour or two BEHAVIOUR breastfeeding for 24 months ( Lozoff and Brittenham 1979 )

123 Maternal behaviour & modern neuroscience mirrors Greek myth... ARTEMIS goddess of the hunt and fertility... ARTEMIS Greek goddess of - the hunt - fertility - virginity contradictions

124 MOTHERING is a high calling... and also neuroscience !


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