Friday, March 13, 2009

Article: Sleeping With Your Baby

Sleeping with Your Baby
Issue 141 - March/April 2007 by Peggy O'Mara

One of the biggest crises of confidence that new mothers face has to do with sleep. Mothers feel responsible for their babies' sleep. Others ask mothers if their babies are sleeping through the night, as if this is something the mothers can control. Mothers lie to one another about whether or not their infants sleep through the night. And everyone lies about not bringing their babies into bed with them.
We lie because our society has unrealistic expectations of babies, and therefore we have unrealistic expectations of ourselves as mothers. Our expectations for babies' sleep simply do not coincide with babies' actual capabilities, or with the normal behavior of our species.
It is normal for human beings to wake during the night. We each awake several times a night, but don't remember that we have. It is normal for human infants, especially, to wake at night. During their early weeks, they sleep during the day and are awake for periods during the night. It takes about two months for their day-night cycle to regulate itself. From two to four months, infant sleep is more predictable, with longer stretches of night sleep. Parents are tempted during this time to say that their babies sleep through the night, and they fully expect that they should be. This is often false hope.
New brain activities—manifested in sitting up, standing, creeping, and crawling, as well as in the eruption of new teeth—conspire to make the period from five to nine months a time of increased night-waking. Baby becomes more aware of others during this time, and may have separation anxiety and nighttime fears.
The pattern of increased brain activity, new growth and stimulation, eruption of baby teeth, and the maturation of the immune system is mostly complete by two years of age. While many parents with one-year-olds who are not sleeping through the night think that their baby has a sleep problem, it is actually not until between two and three years of age that a child regularly sleeps through the night. This does not mean that the two-year-old wakes as much as the newborn, but only that sleep is a process as well as a state.
There is nothing we can do to change this, nothing we can do to make our babies sleep through the night. We sometimes think that introducing solid food will help our babies sleep, but starting solids too early can hurt them. One study found that feeding babies rice cereal before four months was a risk factor for the development of diabetes. The American Academy of Pediatrics recommends not starting solids before six months; the World Health Organization suggests waiting even longer.
Even if we wait to start solids, it is not a good idea to start with rice cereal, although it is very popular. Rice cereal doesn't make babies sleep through the night. In fact, it has a high glycemic index and may raise the baby's levels of blood sugar and insulin. It is not as rich in nutrients or flavor as other foods, such as vegetables and fruits. If food actually did make babies sleep, rice cereal would not be a good choice; as a starch, it is digested quickly. The cereal became popular decades ago to complement formula feeding because it could be more easily fortified with iron.
While we cannot make our babies sleep, we can provide them with regular bedtime routines. I always nursed my babies to sleep in a rocking chair. Baths, quiet time, reading stories, soft light, and a slow pace help prepare children—and adults, for that matter—for sleep. These routines help us to relax.
It is also important that older children have time during the day to run and play, as a lack of exercise can make them wakeful. On the other hand, children who are overstimulated can also take time getting to sleep. We all need a period of unwinding from a busy day, and the transition from waking to sleep requires sensitive pacing.
Most of us, though, can figure out the baths and the bedtime stories. It's the night waking when our children are babies that drives us wild. It drives us wild because we're up in the night and don't want to be. It also drives us wild because it's a dark secret to admit that our babies wake at night.
Over 30 years ago, I sat in a room with a bunch of other new moms and bemoaned the fact that my baby was waking up during the night. I thought I was weird. All of a sudden, it occurred to me to ask the other mothers how many of their babies were waking at night. Nearly all of them raised their hands. We all breathed a great collective sigh of relief. It was not our fault. It is just the way babies are.
After observing my four babies, it is clear to me that teething is a major culprit in night waking. My babies' night waking dramatically decreased after their two-year molars came in, often at about 18 months. There can be other reasons for night waking, and it's always helpful to try to figure out if there is anything out of the ordinary in the baby's life that might contribute to wakefulness. If not, one simply has to live with it.
We have set a cruelly unrealistic standard for infant sleep. We expect babies to conform to our adult world, and we justify coercing them when they don't.
I know it's been a long time since my children were babies, and I no longer feel in my bones the ache of missed sleep, but I found it easier to handle sleep interruptions once I came to accept night waking as normal. I recently received an e-mail advertising the services of a doctor who specializes in sleep training. "Sleep training" implies that we can, and therefore probably should, control our babies' sleep habits. But is sleep a "habit"? Good sleeping habits are one thing, and they do indeed help children sleep better—but sleep itself is a need, and therefore out of our control.
Yet we parents are not only expected to control our children's sleep, we are told where our babies are to sleep. Defying centuries of ancestral wisdom and common practice, today's medical experts raise doubts in young parents about the safety of sleeping with their babies. This advice flies in the face of the fact that most of the world's parents sleep with their babies and always have. It's the way of our species. The assumption that one needs a separate room and a separate bed to safely raise a baby is elitist. There's nothing inherently wrong with these things, but they don't have a monopoly on safe sleep.
Human babies are born helpless and have the longest period of dependency of any species. We are not comfortable with this because our culture equates dependency with weakness. It is, in fact, a healthy dependency that guarantees independence. I don't think I am the only mother who has observed that her most dependent babies turned into her most independent children. As with sleep, independence is not something we can teach our children. It is something they develop.
But what is a parent to do with all of the mixed messages regarding sleep and babies? One doctor recommends swaddling babies all night long. And yet, observation of babies self-attaching to the breast shows them using their arms to locate the breast and to move toward it. Babies also move their arms to lower their body temperature, which is important—overheating can be a contributing factor in SIDS.
Another doctor recommends that parents refuse to comfort a baby who wakes at night. He suggests standing outside the door of the baby's room to listen to her cry it out. I can't imagine any other circumstances in which one would be so deliberately unresponsive to a loved one's suffering. When the baby finally falls asleep out of exhaustion, it is not because she has learned how to sleep. It is because she has given up on others.
Convincing international research supports a parent's instinct to sleep with her baby. Cosleeping seems to have a corrective effect on the infant's respiration. The baby breathes more regularly when in skin contact with the mother. For this reason, too, cosleeping is protective against SIDS. One researcher even found that cosleeping was not only safe, it was twice as safe as not cosleeping.
And yet, the gold standard for infant sleep is an approved crib. According to controversial research conducted by the Consumer Product Safety Commission, each year 60 babies die in adult beds—but most of these babies are alone. On the other hand, 900 babies die each year in cribs, and in the last 25 years there have been 36 recalls of cribs. Does this mean that cribs are unsafe? No. It means that babies sometimes die at night.
It is cruel to suggest to parents that they could be lethal to their own children, and that the only solution is to buy a new crib, which many parents can't even afford. In fact, new products are recalled just as often as old ones. The fact that a product is new does not mean that it has been safety tested, because safety testing is not required. It may mean that it meets current mandatory standards, but if it is a new type of product, there may be no standards yet set for it. This is true even in the juvenile products market.
Common sense tells us that night waking is not a pathological abnormality but a temporary disturbance. It decreases as baby teeth come in and the immune system matures. Here are some ideas that can help:

  • Accept night waking as normal.
  • Sleep when the baby sleeps
  • Don't turn on the light or change diapers when the baby wakes at night to nurse
  • Don't count how many times you're awake at night.
  • Don't look at the clock in the middle of the night.
  • Nap on weekends, or whenever you can get help with the baby.
  • Carry on.

Article: Who Wants to Sleep Alone?

Who Wants to Sleep Alone?
Issue 149 - July/August 2008 by Peggy O'Mara, Editor and Publisher of Mothering magazine

On May 8, the New York State Office of Children and Family Services (OCFS) launched its Babies Sleep Safest Alone campaign, inspired by the deaths of 89 infants or small children reported to the New York Statewide Central Register of Child Abuse and Maltreatment since 2006. "In all of these cases, the child was co-sleeping with a parent, sibling or caregiver," according to the OCFS. I understand that Ohio and Indiana have similar campaigns underway.
When I first heard about this campaign, I was outraged. How dare the government encroach upon our personal lives like that? I was ready to hold a public event to protest the campaign, and immediately e-mailed pediatric anthropologist Meredith Small, and James McKenna, director of the Mother-Baby Behavioral Sleep Laboratory at the University of Notre Dame; McKenna suggested a cosleep-in in Central Park.
After some reflection, I realized that New York's campaign wasn't really directed at me. Like all public health campaigns, it targets everyone in order to reach the few who might actually need to hear the message. Instead of educating parents about the dangers of bed sharing when they're drunk, stoned, medicated, or exhausted, or cautioning against bed sharing with caregivers and siblings, it's easier simply to discourage the practice altogether. The recommendation, however, fails to differentiate between parents with limited resources who bed-share out of necessity, those who do so out of neglect, and those who intentionally bed-share in what they believe to be the best interests of their child.
Before we proceed, it is important to clarify the vocabulary. While the New York State campaign uses cosleeping to mean sleeping with one's baby, this is actually called bed sharing. Cosleeping simply means sleeping in close proximity to your baby, something that both New York State and the American Academy of Pediatrics actually recommend. Some families who cosleep bring the baby into bed with them, some have a side cart on their bed, and others put a portable crib or basinet next to it.
These terms have become politically charged in the last decade as the increase in breastfeeding has been accompanied by an increased acceptability of bed sharing. Bed sharing allows breastfeeding mothers to be less disturbed by nighttime feedings, and thus to get more sleep. Distinguishing between bed sharing and cosleeping, however, can lead to a false dichotomy—in reality, one practice often leads seamlessly to the other. Most people do both: Mom brings the baby into bed to nurse and both fall asleep. The family bed is something born of necessity, not necessarily something that most parents set out to have.
At the root of this debate lie different and contradictory philosophies about what is in the best interests of the child. Some psychologists see bed sharing with children as aberrant in any form, while others see it as an important part of the attachment process. On each side are the usual prejudices and vested interests that can make that side appear "right" to its proponents, and the other side "wrong." Different studies show different results. And, finally, the important distinction between breastfeeding and bottle-feeding mothers in regard to bed sharing is not recognized.
Because of our national superiority complex, we often believe that if something is true here in the US, it must be right everywhere. In the area of infant sleep, this couldn't be further from the truth. According to pediatric anthropologist Meredith Small, the US is unique in being the only nation in the world in which babies are routinely put in their own beds in their own rooms. Small reports on one study that showed that, in 67 percent of the world's cultures, children sleep in the company of others. In another survey of 172 societies, all infants in all cultures do some bed-sharing at night, even if only for a few hours.
Americans didn't talk much about this until 1978, when Tine Thevenin's book The Family Bed was published. Until then, the family bed had been a family secret embraced only by pioneers of natural living and breastfeeding. In 1981, the New York Times went so far as to refer to it as a "medieval" practice. Despite such prejudice, the family bed came out of the closet, and more Americans were willing to admit to what they'd long done secretly.
National Center for Health Statistics data from the state Pregnancy Risk Assessment Monitoring System (PRAMS) from 1991 to 1999 showed that 25.8 percent of new mothers slept with their babies "almost always," and 41.9 percent "sometimes" did, for a combined total of 67.7 percent of new moms who always or sometimes sleep with their babies.
Despite, or perhaps because of, the prevalence of bed sharing in the US, about ten years ago there began to be a more public debate about the family bed. It was then that the terms cosleeping and bed sharing, once considered two overlapping aspects of the same practice, began to be understood and defined as describing two different practices.
This mincing of words has been going on since September 1999, when the US Consumer Product Safety Commission (CPSC) made its first pronouncement specifically cautioning against cosleeping (they actually meant bed sharing). In May 2002, the CPSC issued a statement describing the hidden hazards of adult beds. Like New York State, the CPSC based its recommendations on retrospective analyses—in the case of the CPSC, death certificates—and not on any other scientific evidence.
Because of Mothering's concern that the CPSC was ignoring the relevant evidence and needlessly frightening parents, in 2002 we asked the world's top infant-sleep researchers to write for us on the subject, and we published their responses in a special issue, "Sleeping with Your Baby: The World's Top Scientists Speak Out" (Mothering no. 114, September-October 2002). Here is a sampling of what they said:
James J. McKenna, PhD, is a professor of ?anthropology, and the department chair and director of the Mother-Baby Behavioral Sleep Laboratory at the University of Notre Dame, where he observes mother-infant pairs during sleep. His research on these observations demonstrates that the human infant's body is adapted only to the mother's body, and that cosleeping with nighttime breastfeeding remains potentially lifesaving.
Tina Kimmel, MSW, MPH, PhD, analyzed the data on which the CPSC based its recommendation against bed sharing, and discovered that it was actually more than twice as safe for an infant to sleep in an adult bed as it was to sleep alone in a crib. Looked at another way, Kimmel's data show that crib sleeping is 2.37 times more risky than bed sharing.
Finally, Peter Fleming, CBE, PhD, MBChB, FRCP, FRCPCH, professor of infant health and developmental physiology at the University of Bristol and a pediatrician at the UK's Royal Hospital for Children, Bristol, is considered the top expert in the world on Sudden Infant Death Syndrome (SIDS). He recommends sleeping in the same room with the baby and, if breastfeeding, bringing the baby into bed to feed. He thinks that these and other recommendations will significantly reduce the risk of SIDS. Not all SIDS organizations agree. It is clear that fear of SIDS is a powerful emotional contributor to both the New York State OCFS and CPSC campaigns—groups such as First Candle (formerly SIDS Alliance) warn against bed sharing, implying that it is a possible cause of SIDS.
One reason for these radically different recommendations may be the failure to distinguish not only between intentional and nonintentional bed sharing, but also between breastfeeding and bottle-feeding mother-infant pairs. Helen Ball, Senior Lecturer in Anthropology and director of the Parent-Infant Sleep Lab at Durham University, UK, discovered some significant differences between these two groups in research published in 2004 and 2005. Ball's observations were consistent with the observations of previous sleep-lab studies in regard to mother-infant bed-sharing behaviors. Significant differences were found, however, between formula and breastfed infants. Breastfeeding mothers shared a bed with their infants in a characteristic manner that provides several safety benefits. For example, their sleep positions are oriented to one another, and they experience synchronous arousal during sleep; that is, they wake up spontaneously at the same time for feedings. Formula-feeding mothers, on the other hand, shared a bed in a more variable and thus unpredictable manner, with possible negative consequences for infant safety.
Another reason for these radically different perspectives is that the New York State and CPSC recommendations are based only on epidemiological data within their agencies. It's perplexing that prospective studies such as McKenna's and Ball's—actual observations of mother-infant pairs in sleep labs—are routinely ignored by the government when making recommendations about infant sleep.
All of this rhetoric only confuses parents. Faced with avoidable infant deaths, the New York State OCFS chose to intimidate rather than to educate. I appreciate the challenges faced by OCFS, but parents must take a different tack. Sometimes, public health recommendations can be taken with a grain of salt. Sometimes they are wrong.
As a society, we have learned a powerful lesson regarding certain children's susceptibility to mandatory vaccines. Once outcasts, parents who have fought for vaccine safety are now heroes. While the successful government Back to Sleep program has resulted in a drop in SIDS deaths, it has also resulted in an increase in Positional Plagiocephaly, or flattened-head syndrome. Vitamin D, now recommended for all babies, is an example of public policy instituted to repair the damage caused by earlier public policy. Because of fear of skin cancer from direct exposure to sunlight, we recommend sunscreen for babies. This results in vitamin D deficiency in babies, which in turn requires supplements.
A responsible parent might conscientiously object to vaccines, might want to select only specific vaccines, might delay a child's vaccinations, might have a child be given only one vaccine at a time—or might follow the standard vaccine schedule exactly.
Once her baby can lift his head, a responsible parent might vary her baby's position so that he sometimes sleeps on his back, sometimes on his side, and sometimes on his stomach.
A responsible parent might forgo the supplement and decide that it is safe to expose her breastfed baby to the sun for the 20 minutes a week it takes to get sufficient vitamin D.
In her own and her infant's best interests, a responsible parent might bed-share in the full knowledge that the evidence supports her decision, even encourages it.
Knowing that a parent is the only one ultimately responsible for her child, a responsible parent might just think for herself.

Friday, March 6, 2009

When hearing the news that I had my last baby at home and am planning to have this one at home as well, the first response from most people is, "You're so brave." This has to be one of the most irritating things that people say to homebirthers. The implication is that birth is dangerous and that we are willing to take on a tremendous risk to do it anywhere but a hospital. It negates the research and planning that we've done to come to this decision. It makes the choice about balls, not brains.

After all, homebirth is "dangerous." Hospital birth is "safe."

Therefore, it must be bravado alone that would lead a woman to choosing such an option. Right? In 2003, over 20% of women had their labors induced, with a rate closer to 40% in many hospitals, while that rate should not exceed 10% (and has remained at 10% in most industrialized nations). Inductions are approximately 5 times more likely among planned hospital births than planned homebirths. An 1999 American Journal of Obstetrics and Gynecology "Green Journal" review of 7000 inductions found that 3 out of 4 of the inductions were not medically necessary. Inductions are performed unnecessarily for estimated size of the baby (too large or too small), going past the estimated due date, amniotic fluid levels that are low but not critically low (correctable in nearly all cases by rehydration of the mother), rupture of membranes without immediate start of labor, the mother being dilated/effaced but not in active labor, or scheduling reasons on the part of the mother or care provider. Approximately 40-50% of inductions fail (depending on the induction method used and the mother's Bishop score), and most failed inductions end in cesarean section. Inductions increase labor pain and length, and create, among other problems, an increased risk of fetal distress, uterine rupture, and cesarean section.

But homebirth is "dangerous." Hospital birth is "safe."

Over 30% of women in the US have cesarean sections, while overwhelming research has led the World Health Organization to set an ideal standard rate of cesarean sections at 10-12%, with 15% being the rate where more harm is being done instead of good. Cesareans are performed at a similar rate across all risk groups, low to high. The cesarean rate for planned births at home or in an independent birthing center is approximately 4%. Cesarean sections increase the likelihood of maternal death by as much as 4 times, and have other immediate and long-term heath risks for mothers that include, but are not limited to, infection, bowel or bladder perforation, hysterectomy, future infertility, and increased risk of uterine rupture for future pregnancies. Risks for the baby include respiratory distress, fetal injury, prematurity (if result of schedule section or failed induction), and breastfeeding difficulties. Four of the greatest causes for the increase in cesarean section are overuse of interventions during labor, concern for malpractice/liability on the part of care providers, failed labor inductions, and "failure to progress" (labor not progressing fast enough or regularly enough for care providers).

But homebirth is "dangerous" and hospital birth is "safe."

The ACOG and AMA have both come out against homebirthing, calling it a dangerous trend and referring to it as a "fashionable, trendy, [...] the latest cause célèbre," and they paint a horrible picture of complications arising in low-risk pregnancies with no warning that cannot be handled anywhere but the hospital. Despite that, the most thorough study ever done on homebirth safety, Kenneth C Johnson and Betty-Anne Daviss's Outcomes of planned home births with certified professional midwives: large prospective study in North America, BMJ 2005;330:1416 (18 June), found that the outcomes of planned homebirths for low risk mothers were the same as the outcomes of planned hospital births for low risk mothers, with a significantly lower incident of interventions in the homebirth group. The Lewis Mehl Study of home and hospital births, which matched couples in each group for age, parity, education, race, and pregnancy/birth risk factors, found the hospital group had 9 times the rate of episiotomies and tearing, 3 times the cesarean rate, 6 times the fetal distress, 2 times the use of oxytocin for induction/augmentation, 9 times the use of analgesia/anesthesia, 5 times the rate of maternal blood pressure increase, 3 times the rate of maternal hemorrhage, 4 times the rate of infection, 20 times the rate of forceps use, and 30 times teh rate of birth injuries (including skull fractures and nerve damage). Breastfeeding success rates are higher and postpartum depression rates are lower for planned homebirths.

But homebirth is "dangerous" and hospital birth is "safe."

The United States spends more per pregnancy/birth than any other country, the vast majority of women in the US give birth in hospitals, and yet the US's maternal death rate is the worst among 28 industrialized nations and the neonatal mortality rate is the second worst. The Netherlands, where 36% of babies are born at home, has lower maternal and neonatal mortality rates than the US. Denmark, where all women have access to the option for a safe and legal home birth, has one of the lowest maternal and neonatal mortality rates.

But homebirth is "dangerous," hospital birth is "safe," and Brutus is an honorable man.

I didn't choose a homebirth because I am brave. Bravery has little to do with it. If anything, I believe women who choose to give birth in US hospitals are the brave ones, because knowing what I know about our technocratic obstetrical system, I can't imagine voluntarily choosing an obstetrician and a hospital for anything but absolute medical necessity. My decision to homebirth wasn't made in a void, but based upon years of research. I wonder how much research the average woman puts into her hospital birth? Considering how many times I've heard someone say "I'm glad I was in the hospital because..." and then given as her reason a non-emergent situation (such as fetal size or nuchal cords), I'd say not that much.

Call me stubborn, because I wasn't willing to accept out of hand the culturally held belief that hospitals are safer. Call me an idealist, because I believe that birth can be a positive, safe, and empowering experience for child and mother. Call me a nonconformist, because I choose to birth at home in defiance of a powerful technocratic system. Call me outspoken, because I can't keep my mouth shut when I hear about yet another iatrogenic birth calamity. Call me a "birth nazi," because I believe it's the right and responsibility of every woman to educate herself about birth and take ownership of her birth experience.But brave? Don't call me brave. "Brave" has nothing to do with it.

Thank you to the amazing woman who posted this on the Freebirth/Unassisted birth Facebook group.

oh good golly....






As if I need another time-filler. We'll see how long this lasts!




I like this thought:















I like this one, also: