STRENGTHENING NEWBORN INTENSIVE CARE
In recent decades considerable advances have been made in strengthening perinatal care by focusing
on evidence-based obstetric practices together with a family-centred approach. Evidence-based
knowledge has provided striking and much-needed technological improvement in maternal and
newborn care, but the application of a family-centred approach, particularly when complications
develop in pregnancy and childbirth, has been deficient. Family-centred care is based on recognition
of human rights in perinatal care. While maternal rights have been increasingly recognised – through,
for example, the emerging emphasis on the importance of non-coerced and unbiased informed
choice and consent by mothers – the recognition of neonatal rights has lagged far behind. While
rooming-in and close maternal newborn contact for normal term babies was initiated as early as
1982, (1) and has become an increasingly accepted maternal right worldwide, at least for normal
term babies, such practices are still rarely found in neonatal intensive care units globally. This letter
is a sincere and urgent appeal to the United Nations and other global, professional agencies to raise
awareness of, and to address, this gap in human rights, and family-centred care, in neonatal intensive
care centers.
For decades, high-tech neonatal intensive care units have not given sufficient attention to the human
rights of newborns. In most centers, attention has been paid primarily to the physical aspect of a
baby’s health, neglecting the equally important emotional and social health necessary for
development of a whole human being. At such a time they are psychologically vulnerable. Close
contact with their infant and participation in decisions about their baby’s care is every new family’s
right, yet they are excluded from the NICU environment for some, if not for much of the postnatal
hospitalization period. Caregivers may avoid working in an open, participatory manner that allows
and encourages mothers and families to see and hear everything that happens to her or their child.
Open disclosure and collaboration requires that caregivers explain to parents the need for tests and
treatments for their infant, often resulting in the reduction of unnecessary tests (2). The former
Soviet Union provides a striking case study of an approach that isolates the parents from the infant’s
care. This system is still in place in many of its health care centres. The Soviet system never allowed
mothers to see their babies in the NICUs by order of the Moscow Health Minister. Postpartum
mothers were considered to pose a threat of infection to their children. The ideology of the Western
world and the totalitarian power of physicians in neonatal departments created the myth that they
were ‘almighty’ and could treat children without the presence – or permission - of the mother
(family). Mothers of infants in NICUs in the Soviet Union were expected to play the so-called
‘guest-mother’ role to be able to see their children, often only once a week, with fathers being totally
prohibited from visiting. While this approach is, perhaps extreme, it is by no means unique to the
former Soviet Union countries.
Two alternative, but to some extent complimentary, approaches to maternal and newborn care have
emerged over the past few decades, one in the West and the other in a former Soviet country –
Estonia. The Baby Friendly Hospital Initiative (BFHI) was developed in the West in the 1990s and
was introduced into the former Soviet Union and other countries at about this time, firmly
establishing the importance, and practice of breastfeeding newborns, particularly normal, term
infants. Strongly supported by United Nations agencies such as WHO and UNICEF, this program
went far in creating awareness of optimal feeding methods and the importance of maternal-newborn
contact and closeness from birth onwards. It was not, however, directly addressed towards the
newborn requiring intensive care. In addition, its focus was on the importance of breastfeeding,
rather than on the inherent needs, and rights, of both the mother (family) and the newborn to have
psychologically sensitive and supportive care in addition to good clinical practice. Both the BFHI’s
lack of attention to the NICU setting as well as its neglect of the rights of parents and newborns to
sensitive and supportive comprehensive obstetric and postpartum care were clearly voiced by
Chalmers in the British Journal of Obstetrics and Gynaecology in 2004 (3) .
In contrast, in 1979, a decade prior to the development of the Baby Friendly Hospital Initiative in
the West, a more comprehensive approach to neonatal intensive care was introduced into Estonia by
Dr Adik Levin, a neonatologist at the Tallinn Children’s Hospital. This approach – the Family
Centred Neonatal Care Initiative (formerly called the Humane Neonatal Care Initiative) emphasised
both the importance of breastfeeding babies in NICUs as well as the crucial role played by mothers
and fathers in providing love and continuous, close physical contact with their sick and preterm
newborns from the earliest possible moments after birth. (4-13). Parental involvement in the
physical care of their premature and/or sick infant was also essential in providing adequate technical
care – prompted by a shortage of nursing staff at the time. It is well acknowledged that when normal
term babies are unwell, their mother’s (and father’s) love and close contact provide much needed
(and clinically beneficial) emotional and psychological support for both the infant and its parents.
Yet this need in preterm and sick newborns has been regarded as of minimal or no importance in
contrast to the overarching importance of high-tech, impersonal, medical care provided in isolated
incubators or NICUs away from parental interference and controlled by autonomous health care
professionals. In addition to providing emotional support for their newborns, encouraging mothers
and fathers to play an active and close participatory role in the NICU setting also contributes to
more careful and measured clinical care from caregivers who are held accountable to the parents.
Such sentiments are endorsed by the Pucon Declaration regarding the ‘Humane Neonatal Care
Initiative’ (attached) .
In recent decades, evidence-based practice in obstetric and neonatal care has been clearly
acknowledged globally and increasingly frequently introduced. At the same time there has been
growing awareness that psychosocially sensitive and family centred care during pregnancy and at
labour and birth, are also crucial to providing a psychologically healthy start to the new family.
Again, these developments have largely but not exclusively – been applied to the normal pregnancy.
Today, it is incomprehensible to believe that ‘good’ (and satisfying) parenting experiences and
practice – including the challenging task of caring for a sick and preterm newborn - could be
conceived of occurring without tremendous emotional and practical support for such parents, both at
the time of birth and in the following postnatal period. With the rise of preterm obstetric intervention
(particularly induction), increased use of assisted reproductive technologies, as well as the
increasing rate of birth among older mothers – all of which are contributing to an increased number
of newborns being admitted to NICUs - the importance of providing psychologically supportive care
during pregnancy, at birth and especially when their infants are admitted to NICUs, is becoming
increasingly crucial.
While the UNICEF/ WHO Baby Friendly Hospital Initiative was eagerly supported for a decade or
so following its introduction in the early 1990s, (14) financial and organizational support from these
UN Agencies has been largely withdrawn in recent years. Sadly this support was lost before the
movement could be clearly extended into NICUs or to encouraging psychologically supportive
obstetric and neonatal care that respected human rights of the newborn and mother or family. In
recent years an Oslo based group has drawn attention to the need to apply the breastfeeding
principles incorporated in the Baby Friendly Hospital Initiative into the NICU setting.(15) While
this movement to enhance the use of human milk in the NICU is to be admired, it again relegates the
importance of acknowledging the human rights and psychological needs of sick and preterm
newborns, to a secondary role. It falls short of taking a necessary and comprehensive approach to
providing optimal care for babies admitted to NICUs – one that ideally incorporates rooming-in of
mothers with their babies 24/7, breastfeeding and/or breastmilk for neonates, and maternal or family
care of the baby in conjunction with professional medical attention. This program requires a clear
recognition of the human rights and psychological needs of both parents and their sick and preterm
newborns. The Oslo development threatens to repeat this error of omission by focussing primarily
on the breastfeeding of newborns in NICUs without fully considering and developing a program that
incorporates the psychological needs as well as the human rights of newborns and their parents in
this environment. This letter serves as an urgent request to consider the matter in its full context and
not to, yet again, provide an incomplete approach, as proposed by the Oslo initiative, to resolving
this issue.
The name ‘Baby Friendly Hospital Initiative’ has, in reality, been largely misleading. It is, in
essence and as originally conceived, a Breastfeeding Friendly Hospital Initiative. To be truly ‘Baby
Friendly’, hospitals need to incorporate both breastfeeding support as well as ‘friendly’ or
emotionally and psychosocially supportive obstetric and neonatal care, which is respectful of the
human rights of babies and their parents. We appeal to you to truly live up to the full potential of the
name “Baby Friendly Hospital Initiative’ in future developments. It is our sincere hope and wish
that the Committee for the Rights of the Child (CRC), the headquarters of the WHO in Geneva, and
such regional offices as Copenhagen and New York, as well as the headquarters of UNICEF in
Geneva and New York, at least, will heed our appeal to take urgent action to meet the rights and
needs of newborns and their parents in NICU settings in the most comprehensive and appropriate
manner.
The signatories to this letter call upon you to discuss the problem of how to protect both the rights of
children (newborn and premature) and mothers (families) in hospitals/ maternity hospitals as well as
to draw up an internationally accepted relevant program /document. The professionals who have
signed this letter are all staunch supporters of breastfeeding, having contributed to strengthening
breastfeeding of all newborns, but also stand for the human rights of both children and mothers
(families) as a priority. We pledge our support and assistance in developing such a comprehensive
program.
Signatories:
Dr Adik Levin MD, Ph.D, MSc.D.FABM.
Head of Neonatal and Infant Department 1979-2004, Tallinn Children’s Hospital
Candidate UN CRC from Estonia 2004-2005
Tallinn, Estonia
Dr Beverley Chalmers (DSc(Med); PhD)
Adj Full Prof, Dept Obstetrics and Gynaecology
Affiliate Investigator, Ottawa Hospital Research Unit
University of Ottawa
Ottawa, Canada
Mary Renfrew
Professor of Mother and Infant Health
Mother and Infant Research Unit
School of Nursing and Midwifery
Director, Applied Health Research
College of Medicine, Dentistry, and Nursing
University of Dundee
11 Airlie Place
Dundee DD1 4HJ
UK
Michael S. Kramer, MD
Professor,
Departments of Pediatrics and of Epidemiology, Biostatistics and Occupational Health,
McGill University,
Faculty of Medicine
Montreal, Canada
Janusz Kaczorowski PhD
Professor and Research Director
Holder of the Docteur Sadok Besrour Endowed Chair in Family Medicine
Holder of the GSK-CIHR (GlaxoSmithKline-Canadian Institutes of Health Research) Endowed
Chair in Optimal Management of Chronic Disease
Department of Family and Emergency Medicine
University of Montreal
University of Montreal Hospital Research Centre (CRCHUM)
Head: Health Care Systems and Services, Hôtel-Dieu
Fernando Pinto (MD)
Pediatrician
Child Neurologist
Full Professor of the University of Chile
Past-Director of the "Paediatric, Infant Surgery and Child Neurology Department of the University
of Chile" ,reelected during 3 periods ( 12 years ).
Past-¨President of the Chilean Pediatric Society.
Past Director of the Chilean Society of Pediatric Neurology
Past Vice¨President of the Chilean Society of Ultrasound in Medicine.
Head of Pediatric Department In Coyhaique Hospital.
GJ Hofmeyr
Effective Care Research Unit,
University of the Witwatersrand/FortHare;
Eastern Cape Department of Health.
South Africa
Dr Nanette Jolly MB BCh IBCLC
Port Elizabeth
South Africa Nan Jolly
Nora Klein
Associate Clinical Professor, Pediatrics
Baylor College of Medicine, Houston, Texas
Fellow of American Academy of Pediatrics: breastfeeding Section
Fellow of the Academy of Breastfeeding Medicine
Member, Texas Pediatric and Houston Medical Societies
Matias Viera (MD)
Paediatrician
Past Prsident Punta Arenaas Pediatric Society,Subsidiary of Sociedad Chilena de Pediatria
Former Head Pediatric Dept, Hospital Arenas Punta Arenas, Chile
Professor Elza Akhmadeeva, MD, PhD
Chair of the department of Pediatrics
at Bashkir State medical University
Chair of the Bashkir branch of Russian Association of Specialists in Perinatal Medicine
Professor Leila Akhmadeeva, MD, PhD, MBA, JD
Professor at the department of Neurology, Neurosurgery and Medical genetics
Chair of International Office
at Bashkir State medical University
Chair of the Bashkir branch of Ineterregional Society of Specilists in Evidence Based Medicine
Sallie Page-Goertz, MN APRN, IBCLC, FILCA
Clinical Associate Professor of Pediatrics
Kanas University School of Medicine
Audrey Naylor. MD, DrPH, FAAP, FABM
President and CEO
Wellstart International
and
Clinical Professor of Pediatrics
University of Vermont College of Medicine
Concepción de Alba, PhD MD
Assistant Physician in the Department of Neonatology, Hospital 12 de octubre, Madrid, Spain
Professional in NIDCAP
Professor in Paediatrics UCM
IBCLC
ASYA S. MU'MIN
CPT, MD, MC, US ARMY
Tripler Army Medical Center
Honolulu, Hawai'i
Nadia Badrawi
Chair of the Board
Nile Badrawi Hospital
Prof.of Pediatrics & Neonatology
Cairo University
Kathy Leeper, MD, IBCLC, FABM
Medical Director, Milkworks- a nonprofit breastfeeding center
5930 South 58th St, Suite W Lincoln, NE 68516
USA
Mariana Colmenares. MD, Pediatrician, IBCLC.
Hospital Médica Sur Tlalpan
México City
Patrice DeMarco
Motherbaby Unit
Fletcher Allen Health Care
111 Colchester Avenue
Burlington, Vermont 05445
Lydia Furman MD FAAP
Associate Professor of Pediatrics
Rainbow Babies and Children's Hospital
References:
1.
Klaus HM, Kennel JH. Parent-infant bonding. 2nd ed. St Louis: CV Mosby, 1982
2.
Levin A. Where are you going, neonatal medicine? (Letter to the Editor). News and views
from Estonia. Initiative Crit Care Nurs 1995; 11: 49-52.
3.
Chalmers, B. The Baby Friendly Hospital Initiative: Where Next? British Journal of Obstetrics
and Gynaecology, 2004, 111(3), 198-199.
4.
Levin A. The Mother-Infant Unit at Tallinn Children’s Hospital, Estonia: A.Truly BabyFriendly Unit. Birth 1994;21: 39-44.
5.
Harrison L and.Klaus M, Commentary: A Lesson from Eastern Europe“ Birth 21:1 March
1994;45-6.
6.
Levin A., von Mühlendahl KE Familienfreundlichkeit von Kinderkrankenhäusern in Estland
und Deutschland. Internationale Sozialpädiatrie 1994;16(7): 430-431.
7.
Levin A. Humane Neonatal Care Initiative. Viewpoint. Acta Paediatrica 1999; 88: 353-355.
8.
Kennell JH . The Humane Neonatal Care Initiative Acta Pædiatrica 1999; 88: 367 -370.
9.
Chalmers B, Levin A. Humane Perinatal Care. TEA Publishers, Tallinn, 2000 .
10.
Medical-Psychological Work with Mothers in Neonatal Unit. VI Jornada Chileno - Argentina
de Pediatria: Cuidados Humanos en la Pediatria del III Mileno. Coyhaique, Chile. 17-19.April
2000.
11.
Tecnicas de Humanizacion en el Manejo del Prematuro. XLI Congreso Chileno de Pediatria.
Pucon (Chile) 28 de Noviembre al 1 de Deciembre 2001. Pucon Declaration 28.11.2001 Pucon
Chile.
12.
Levin.A Letter to Editor Are NICUs Baby-Friendly or Breastfeeding-Friendly? Birth, 2013;
40(2) 152-153.
13.
O’Brien K, Bracht M, MacDonnell K, McBride T, Robson K, O’Leary L, Christie K, Galarza
M, Dicky T, Levin A, Lee SK. A pilot cohort analytic study of Family Integrated Care in a
Canadian neonatal intensive care unit. BMC Pregnancy and Childbirth 2013, 13 (Suppl
1):S12 doi:10.1186/1471-2393-13-S1-S12.
14.
Wolf H, Charrondiere R, Helsing E. First "baby-friendly" hospital in Europe. Lancet 1993,
341: 440.
15.
The BFHI Initiative in Neonatal Units. Proposal from a Nordic and Quebec working group.
Three guiding principles and ten steps supporting Breastfeeding and Family/centered care.
Draft for the 1st International conference and workshop on the expansion of the Baby Friendly
Hospital Initiative in Neonatal Units. 14th-16th September 2011 in Uppsala, Sweden
PUCON DECLARATION
XLI Chilean Paediatric Congress. Pueõn, Chile, November 28, 2001
The Chilean Society of Paediatrics is committed to promote the
"HUMANIZATION OF PERINATAL PAEDIATRICS".
This commitment means to put emphasis on maternaI involvement in the care of the
newborn and preterm infant as well as on the protection of the rights to be breastfed,
to develop a sound mother-child bonding and to get a good care in every
circumstance, including the hospitalization in intensive care units.
This Society wishes to acknowledge the extreme value and positive consequences
of the" Baby Friendly Hospitals" initiative and states its recognition to PAHO/WHO,
UNICEF and other international organizations working to spread these ideas which
have been planted in our and other countries.
Our commitment goes beyond the protection of breastfeeding for a minimun of six
months and extends to maternaI involvement and inclusion of the mother as an
active-not passive- protagonist of child care ideally with the longest possible
contact with her ehiId, namely during the 24 hours of the day.
Furthermore, points to the highest rationalization of laboratory tests and treatments
to diminish or eliminate physical and psychological pain and to support skin contact
between mother and ehiId.
In accordance with these statements during the XLI Chilean Paediatric Congress in
Pucon, Chile, this society and all its members, in the presence of Professor Adik
Levin subscribe and endorse the 11 points of the Tallin Hospital, Estonia,
methodology: "The Humane Neonatal Care Initiative" aimed to the humanization of
newborn care.
To accomplish this goal our institution invites all the Paediatric Societies of the
world to subscribe to this declaration and asks for support from all the international
organizations working for the health, well being and rights of Man and Child.