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 
1 Introduction
2 Restriction of early mother–infant contact
3 Control of infection
5 Drugs for relief of symptoms
6 Length of hospital stay
7 Support and education
7.1 General support and education
7.2 Support for mothers with special needs
9 Conclusions
A new mother needs both emotional support and practical help in the days following childbirth. The form that this help takes, and the way it is given, varies from culture to culture and from time to time. The shift from home to hospital, as the usual place of birth in the twentieth century, has influenced the pattern of mother–baby interaction in at least two ways. First, a woman who gives birth in unfamiliar surroundings, attended by caregivers who she does not know, may feel inhibited and behave differently towards her newborn child than she might at home among familiar faces. Second, institutional rules and policies may obstruct spontaneous social interaction between a new mother and her baby.
The only justification for practices that restrict a woman’s autonomy, her freedom of choice, and her access to her baby, would be clear evidence that these restrictive practices do more good than harm.
Evidence about the adverse consequences of routine separation of mothers and their newborn infants in the early postnatal period,
S
OURCE
: Murray Enkin, Marc J.N.C. Keirse, James Neilson, Caroline Crowther, Lelia Duley, Ellen Hodnett, and
Justus Hofmeyr. A Guide to Effective Care in Pregnancy and Childbirth , 3rd ed. Oxford, UK: Oxford University
Press, 2000.
D
OWNLOAD
S
OURCE
: Maternity Wise ™ website at www.maternitywise.org/prof/
© Oxford University Press 2000

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    accumulated during the thirty years or more during which this practice was widespread. Several controlled trials have compared the effects of institutional policies that restrict interaction between mothers and their newborn babies in the early hours after birth with policies that encourage interaction at that time. Maternal affectionate behavior was significantly less evident among mothers whose contact with their baby had been restricted than among mothers whose care encouraged liberal contact.
Trials have also compared standard hospital practices with attempts to encourage mother–infant interaction after the immediate postnatal period. The additional interaction in these trials ranged from a small amount of caretaking in the intensive-care nursery by mothers of preterm infants, to full rooming-in for mothers of normal infants. The few statistically significant differences that were observed suggest that restrictive policies were associated with less affectionate maternal behavior and more frequent feelings of incompetence and lack of confidence. Perhaps most important of all, the results of one well-conducted study suggests that, compared with a policy of rooming-in, the routine hospital policy of separating mothers from their babies led to an increase in the subsequent risk of child abuse and neglect among socially deprived, first-time mothers.
Hospital policies can affect subsequent breastfeeding patterns among women who wish to breastfeed their babies. In all trials that have addressed this question, the proportion of women who discontinued breastfeeding in the first 3 months was substantially higher among women who had been subjected to more restrictive policies.
Maternal caretaking behavior is so essential to the newborn baby that a variety of biological and social mechanisms must have evolved to promote it. The mutually reinforcing affectionate behavior that occurs during early postnatal mother–infant contact is only one such mechanism. It is not the only mechanism. Most mothers who are constrained from early contact with their babies, whether through illness, misguided hospital policies, or personal preference, are likely to overcome any effects of this separation in the longer term.
Many of the regulations and routines in hospital postpartum care were instituted as attempts to prevent or contain cross-infection. As hospital nurseries began to fill up with members of the baby boom that followed

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    the Second World War, staphylococcal skin disease among neonates became the major infectious problem. A variety of measures were taken in attempts to deal with this problem, including isolation, segregation, rules of dress and entry to the nursery, medicated bathing, and special treatment of the umbilical cord.
The inflexible use of central nurseries, in which a number of babies were kept in close proximity to each other but apart from their mothers, may actually have increased the risk of infection. A study performed almost 50 years ago showed lower rates of colonization and infection in babies who spent between 8 and 12 hours a day with their mothers, than in babies who were kept in a nursery and were rarely in contact with their mothers. The results of this controlled study had little impact on the then almost universal policy of routinely separating mothers and babies. Instead, the problem of cross-infection and nursery epidemics of staphylococcal infection was addressed with more technological approaches. The use of gowns, hats, and masks in nurseries became routine, despite the lack of any evidence from controlled trials that they reduced infant colonization and infection rates.
As segregation and isolation failed to control neonatal infection, the mainstay of infection prophylaxis shifted to regimens of treatment of the umbilical cord and medicated bathing. Questions about various regimens for umbilical cord care have been addressed in studies that compared application of an antiseptic with no antiseptic, antibiotics versus antiseptics, powders versus no powders, and closed versus open dressings. Studies of bathing have compared medicated bath water with unmedicated bath water, and routine daily bathing while in hospital with an initial bath only. All the studies were conducted in developed countries, on healthy term infants. Under these circumstances there is no evidence of benefit from any form of cord care beyond keeping the cord clean, and the available evidence suggests that routine bathing
(medicated or otherwise) of babies is not justified.
Hospital practices vary widely. With the increasingly widespread practice of 24-hour rooming-in for healthy mothers and babies, normal newborn nurseries have become obsolete in some hospitals. In those hospitals that retain newborn nurseries, however, many restrictive and costly practices remain in force. Gowning rules persist in almost three-quarters of newborn nurseries, despite the lack of evidence that this ritual has any beneficial effect. Many hospitals invoke concern about infection as a reason for restricting or forbidding siblings to visit, although studies using concurrent and historical

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    control groups have been unable to detect any adverse effect of this on infant colonization rates.
It would be extremely dangerous to take a cavalier attitude to the undoubted reality of hospital-spread infection among new mothers and babies. Means for preventing or containing such infections must be kept under constant review. But maintaining or instituting restrictive measures without assessing whether or not they accomplish these ends is not an appropriate response. Unrestricted contact between mothers and babies, as with 24-hour rooming-in, is believed to be protective, in that the infants become colonized with the organisms of their mothers rather than the antibiotic-resistant organisms prevalent in hospitals.
Making and recording regular measurements of temperature, pulse, blood pressure, fundal height, and observations of lochia and the various wounds that a woman may sustain during childbirth, is still common practice in the days following childbirth. The intensity of this screening activity varies arbitrarily and depends more on the hospital in which a mother happens to give birth, and on the length of time she spends in it, than on her individual needs. While it is prudent to observe women in this way when they are known to be at increased risk of either infection or hemorrhage, it is difficult to justify this as a routine for all women.
The postpartum period is often accompanied by a number of discomforts. Pain in the perineum and breasts (discussed in other chapters) is common. After-pains (uterine spasms) can also cause pain and distress in the first 4 days after birth. Women not infrequently count these symptoms among the most unpleasant memories they have of childbirth.
In most hospitals, medication for such discomforts tends to be under the direct control and supervision of hospital personnel. This policy is valid in the case of dangerous drugs, drugs that might interact with other medications, or those that would normally be available

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     only on a doctor’s prescription. It does not make sense for drugs that outside hospital, are readily available without a prescription. Because these medications are usually for the relief of symptoms, it would be more reasonable for women to use them when they feel the need to do so.
In many hospitals, non-prescription drugs intended for the relief of symptoms are still administered routinely and at set times. Professional belief in the value of early and regular bowel evacuation, for example, has led to some rather obsessional concerns on this matter. Laxatives, stool softeners, enemas, and anal ointments, remain routine components of postpartum care in some hospitals. In the puerperium, as at other times, routinely prescribed laxatives and medicated enemas do result in earlier bowel movements, and bulk-forming laxatives are less likely to cause unpleasant cramps and diarrhea than are irritant laxatives. This cannot be regarded, however, as justification for administering any of these preparations routinely.
In an attempt to provide a more rational basis for care (including self-care), a number of hospitals have developed programs to provide mothers with information about the drugs they may use, and have given them access to their own supply of medications. These descriptive studies all suggest that women are usually pleased with these arrangements and that staff time is used more efficiently after their introduction.
Routine medications for ‘non-symptoms’, such as oral ergometrine with the aim of hastening uterine involution, should not be used without evidence of a beneficial effect on substantive outcomes.
How long should a healthy woman and baby remain in hospital after childbirth? The generally accepted ‘correct’ length of postnatal stay has varied greatly from time to time and varies equally widely among institutions today. It appears to be determined more by fashion and the availability of beds than by any systematic assessment of the needs of recently delivered women and their new babies.
The period of ‘lying in’ in industrialized societies had its institutional foundations with the establishment of charitable lying-in hospitals in the mid-eighteenth century. In these first maternity hospitals, women were, quite literally, confined to bed for a period of 28 days following delivery! By the 1950s, the usual hospital lying-in period was 12–14

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    days but, since then, it has fallen in most countries and frequently it is no more than 1–2 days.
Several formal early discharge programs, often with strict inclusion criteria, have been instituted as a deliberate change from standard hospital policies. The most common impetus for initiating such programs seems to have been the needs of the institution (because of a shortage of beds or personnel), although some programs appear to have been inspired by the preferences of childbearing women.
Both randomized trials and observational studies have shown that few women or babies are re-admitted to hospital after early discharge.
These low re-admission rates demonstrate that early discharge from hospital is feasible and that healthy mothers and babies who have help at home, and follow-up care and guidance available, may safely go home within a few hours of birth.
Although no adverse consequences of early postnatal discharge from hospital have been demonstrated in terms of maternal and child health, there is also no evidence that such programs save money or resources, unless beds are closed as a result. If home support is provided, the costs of support given to women discharged early have been estimated to be about the same as the savings in hospital costs that result from earlier discharge. Also, when healthy women go home earlier, those remaining in hospital are, on average, more sick, require more intensive care, and involve additional work and strain for the staff. Early hospital discharge programs inevitably put an additional load on the primary care sector and on the family or friends of the woman. The additional resources required to cope with this load must be assessed in any credible attempt to assess the costs of early discharge from hospital.
Demands for early discharge programs have been made by a variety of activists who believe themselves to be speaking on behalf of childbearing women. When such programs have been instituted, they have not always been popular. The extent to which women who give birth in hospital want early discharge may have been overestimated, and may depend on the support available at home.
Women’s physical, social, and psychological circumstances after delivery vary greatly. Professionals should be as flexible as possible in response to this variation; this may be easier in situations where there is continuity of care. Choice may well be the crucial issue. Some women may feel that their hospital stay was too long, while others feel it was too short. Perhaps a more extended escape from duties at home would have helped some women to recover from childbirth more effectively.
Although early discharge from hospital is feasible and safe, it is

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    neither clearly beneficial (in either health or economic terms) nor wanted by the majority of women. Firm decisions about when a woman should go home after childbirth should be delayed until after she has given birth and, as far as possible, be based on her individual needs and preferences, rather than on any predetermined formula.
7.1 General support and education
Fragmentation of care is almost inevitable when the care of mothers is the responsibility of midwives or postpartum nurses and obstetricians, while care of the babies is carried out by nursery nurses and pediatricians. Consistent advice and continuity of care are prerequisites for effective support to mothers and their newborn babies. This is easier to achieve if mother and baby are accommodated together or, at the very least, if the same people are looking after both of them. The postpartum stay in hospital presents clear opportunities for imparting information that may be of help to new mothers. Although there is little agreement on what should be the content of formal postpartum educational programs, a number of studies, several of them controlled trials, have addressed the methods of postpartum education. These studies have dealt with educational programs including subjects ranging from contraception, through feeding and immunization advice, to information about child safety. Although the demonstrable effects of teaching were rarely as dramatic as the investigators had hoped, this body of research shows that postpartum educational programs can, and do, favorably affect parental behavior and health outcomes.
7.2 Support for mothers with special needs
Providing a hospital telephone service to offer advice or information by postpartum nursing staff to new parents is believed to be of benefit, but the only controlled study of this practice did not evaluate it in terms of effects on mothers’ or babies’ well-being, and there have been no economic evaluations of this practice.
Eleven controlled trials have evaluated the effectiveness of additional home-based support for mothers and babies who were believed to be at risk because of social disadvantage (related to poverty, ethnicity, social isolation, marital status, and/or age). In most studies, the additional support involved regular home visits by a specially trained,

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    experienced mother from the community. The mothers who received home-based support were less likely to have infants with incomplete well-child immunizations, and their babies were less likely to be hospitalized in the first year of life, suggesting that home-based support for families with special needs may help to prevent childhood injury and serious illness.
Lack of social and psychological support during the days and weeks after birth is one of the main reasons that unhappiness after childbirth is such a common problem, estimated to occur in 7–30% of women in developed countries. This has traditionally been seen as a medical subject, labeled ‘postpartum depression’. There is no persuasive evidence to support traditional explanations of postpartum depression. No biochemical explanation of women’s unhappiness after childbirth has been uncovered, and psychoanalytic explanations of postpartum depression cannot be validated empirically. Mothers of young children are often depressed and are no less likely to be so
6 months or a year after giving birth, than in the first few weeks or months following childbirth. Sociological and psychological studies have provided strong evidence of a relationship between some social conditions and postpartum depression. The social conditions linked with depression are only rarely ‘out of the ordinary’; more often, they correspond to social expectations about what normal womanhood and normal motherhood must be.
Because many of the social factors that lead to postpartum unhappiness are rooted in society’s expectations of new mothers, the solutions lie mainly in social change. There is considerable scope, however, for professionals to reduce the difficulties and unhappiness experienced by women after childbirth. In particular, they should be more ready to listen to women, to learn about their social circumstances, and to provide them with information that will lead to more realistic predictions about the experience of pregnancy, childbirth, and early parenthood.
If, in spite of the best efforts being made to prevent the problem, women do become seriously depressed, then encouraging them to talk about their feelings to a non-judgmental person has been shown in controlled trials to increase their chances of early recovery.

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 
The restriction of early postnatal mother–infant interaction, which has been such a common feature of the care of women giving birth in hospitals, has undesirable effects. Disruption of maternal–infant interaction in the immediate postnatal period may set some women on the road to breastfeeding failure and, possibly, alter their subsequent behavior towards their children. Nevertheless, for mothers who, for whatever reason, cannot have early contact with their babies, other mechanisms are likely to overcome any effects of this separation.
Most of the restrictive practices perpetuated in some hospitals are ineffective and possibly harmful. Unless or until new evidence appears to the contrary, mothers should have unrestricted access to their babies.
Caps and masks should be abolished, and aprons and gowns used only by those who wish to protect their own clothing from the various kinds of messes that babies make. Bathing the baby should be seen, not as a measure for preventing infection, but as an opportunity for a mother to interact with, and gain confidence in, handling her child.
There is no evidence to warrant the use of routine prophylactic medications or medicated bathing to prevent infection of the umbilical cord.
The standard hospital setting, with its orientation towards sickbed protocols and procedures, and its division of care along the lines of the separate medical disciplines of obstetrics and pediatrics, is not conducive either to helping the new mother develop the skills and selfconfidence she needs to care for herself and her new baby, or to enhancing her sense of personal worth and self-esteem. It is unlikely that any single scheme of care will prove to be right for all women.
Treating the new mother as a responsible adult by giving her accurate and consistent information, letting her make her own decisions, and supporting her in those decisions, is the essence of effective postpartum care, regardless of where it given.
Postnatal follow-up programs for mothers and babies that offer home based social support and continuity of caregiver, and which are sensitive to the social circumstances of families, provide important benefits for socially disadvantaged mothers and their children.
Depression in the postpartum period is a common and serious complication in developed countries. It appears to be related to social rather than hormonal or psychological factors, and there is evidence that women benefit from additional support and counselling, alone or in conjunction with medical therapy.

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   
Effective care in pregnancy and childbirth
Romito, P.
, Unhappiness after childbirth.
Rush, J., Chalmers, I. and Enkin, M.W.
, Care of the new mother and baby.
Thompson, M. and Westreich, R.
, Restriction of mother–infant contact in the immediate post-natal period.
Cochrane Library
Hiller, J.E. and Griffith, J.
, Education for contraceptive use by women after childbirth.
Hodnett, E.D. and Roberts, I.
, Home-based social support for socially disadvantaged mothers.
Lawrie, T.A., Herxheimer, A. and Dalton, K.
, Oestrogens and progestogens for preventing and treating postnatal depression.
Ray, K. and Hodnett, E.D.
, Caregiver support for postpartum depression.
Stamp, G. and White, G.
, Psychosocial support for preventing postpartum depression [protocol].
Zupan, J. and Garner, P.
, Topical umbilical cord care at birth.
Other sources
Carty, E.M. and Bradley, C.F.
(1990). A randomized, controlled evaluation of early postpartum hospital discharge. Birth , 17 , 199–204.
Dalby, D.M., Williams, J.I., Hodnett, E. and Rush, J.
(1996). Postpartum safety and satisfaction following early discharge. Can. J.
Pub. Health , 87 , 90–4.
Rush, J. and Kitch, T.
(1991). A randomized, controlled trial to measure the frequency of use of a hospital telephone line for new parents. Birth , 18 , 193–7.
Tulman, L. and Fawcett, J.
(1991). Recovering from childbirth: looking back six months after delivery. Heal. Care Wom. Int ., 12 , 341–50.