Booby Traps Series: Staff motivation can get in the way of Kangaroo Care and Skin-to-Skin

This post is the 23rd in a series on Booby Traps made possible by the generous support of Motherlove Herbal Company.

To borrow a phrase, if there were a drug that could do the following things for premature and/or term infants, would it be ethical not to use it?

• Better survival rates in preterm babies
• Better oxygenation
• Better heart rate*
• Better temperature
• Opportunity to self attach to the breast
• Lower stress hormones
• Less crying
• Better blood sugars
• Better immunity, even six months later
• Lowered risk of infection
• Lowered risk of necrotizing enterocolitis
• Increased maternal attachment
• Increased breast milk supply
• Increased maternal confidence in ability to care for babies
• Increased maternal confidence that their babies are well cared for
• Increased maternal sense of control
• Better rates of breastfeeding, even many months later**

The ‘drug’ is your skin, in contact with your baby’s skin.  All of these things occur when your baby is held in skin-to-skin contact with you. 

Research has even shown that our chest temperature automatically increases right after birth - a built in “warmer” for our babies.  And since I have your attention, I’m going to take this opportunity to share my favorite trivia about skin-to-skin:

1) If you graph a baby’s temperature in an incubator, which uses a sensor to gauge a baby’s temperature and raise or lower the warmth, the graph will show the baby’s temperature in a wave-like pattern because there is a delay as the incubator responds to the baby’s temperature.  Compare that to a baby on its mom’s chest.  What does the graph look like?  A straight line.  The mother’s chest raises and lowers the temperature instantaneously.  Beat that, machine.

2)  If you place twins on their mother’s chest, one on each breast, each breast will raise and lower its temperature independently to meet the warmth need of each baby.

Though it’s logical to assume that this has been practiced for ages by mothers, research demonstrating the benefits of keeping babies in their natural habitat (mothers’ bodies) dates to 1979, when two doctors in Bogota, Columbia stumbled upon a dramatic finding.

Drs. Rey and Martinez were trying to care for preterm infants in an extremely resource-poor environment.  There was a shortage of warmers.  The mortality rate of premature infants there was about 70%.  Then, they began recommending that mothers hold their babies, skin-to-skin between their breasts as much as possible, and breastfeed on cue.

A miraculous thing happened:  the mortality rate of their patients wasn’t 70%.  It was 30%.

This practice became known as Kangaroo Care, and subsequent research in many other developing countries confirmed their findings.

The next question that needed to be answered was whether there was any benefit to full term babies.  And the answer, established by this review of 18 studies, is a resounding yes.  The World Health Organization fully supports it for all babies, declaring: “Almost two decades of implementation and research have made it clear that KMC is more than an alternative to incubator care. It has been shown to be effective for thermal control, breastfeeding and bonding in all newborn infants, irrespective of setting, weight, gestational age, and clinical conditions.”

So, are hospitals fully supportive and encouraging of Kangaroo Care and skin-to-skin?  I think that it’s safe to say that things are moving in that direction, but there is a lot of work yet to be done.

The most obvious place to look for progress is in the nation’s NICUs, since evidence for Kangaroo Care has been around the longest for preterm babies.  A national survey in 2002 found that 82% of NICUs were practice kangaroo care, and I would imagine that that number has increased in the ten years since.  But barriers exist, even there, and one of the key reasons is staff education and motivation.

The survey found that the practice of Kangaroo Care was more strongly influenced by perceptions than evidence.  As summarized in this article, it found that “Staff reluctance seemed particularly focused on the misconception that kangaroo care would require extra work on their part.” Another study published in 2011 which looked into barriers to kangaroo care found, “Key institutional factors were education and motivation of staff.”

While I couldn’t find any national data on the use of skin-to-skin in full term babies, I can say that I’ve heard similar objections to routine skin-to-skin care.  There is a perception that encouraging moms to hold their babies skin-to-skin will create more work for hospital staff, when in fact the opposite appears to be true.  Babies held skin-to-skin cry less, feed better, and need less care generally because they are in a much more stable state.  Moms are happier, too, and isn’t it possible that this results in fewer call buttons being pushed?

Culture change is hard, and takes time, but the evidence in favor of Kangaroo Care and skin-to-skin makes encouragement of these practices an imperative.

Did your hospital encourage skin-to-skin (or kangaroo care, if you had a preemie)?

* As with breastfeeding, we could discuss these outcomes in terms of the risks of not holding a baby skin-to-skin, rather than “better” rates associated with holding a baby skin-to-skin.  For example, we could say “When a baby is separated from its mother, its heart rate slows to an abnormally low rate as part of a “protest- despair” response.   A return to skin-to-skin contact with the mother restores a normal heart rate.”  Another example:  “A baby removed from its mother is at higher risk for hypothermia than a baby in its normal state - held skin-to-skin with its mother.”

** Skin-to-skin is great for all babies, whether breastfeeding or not.