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Review of Bonding: Recent Observations That Alter Perinatal Care by Kennell and Klaus

Review from Birth Gazette, Vol. 14, No. 4, Fall, 1998
Bonding: Recent Observations That Alter Perinatal Care
By John H. Kennell, MD, and Marshall H. Klaus, PhD
Pediatrics in Review, Volume 19, Number 1, January, 1998

John Kennell and Marshall Klaus have been studying and publishing their work about the bond between parents and their babies for nearly three decades, with the aim of improving perinatal care routines and reducing the incidence of parenting disorders such as child abuse, neglect, failure to thrive, and abandonment.  Their contribution to the evidence surrounding these problems has greatly influence research trends and study design standards.  In this article, they discuss the principles of attachment and bonding, review the most recent literature on bonding, answer some of their critics, and refine some of the observations they have mad previously.

Klaus and Kennell's previous writings have emphasized the en face position as one of the measures of how strong a maternal-newborn bond is.  This is the position in which the mother with a strong bond with her baby holds her so she can look into her eyes.  The refinement to this concept is their recognition that such an idea depends a great deal upon the culture of the mother being observed.  For instance, many Southeast Asian mothers ritually do not hold their babies in the en face position, as doing so would interfere with their deepest cultural assumptions (the "evil eye" will harm their babies if they show admiration and love).  Obviously, the intention here is to inform caregivers that it is usually not a sign of neglect when Southeast Asian mothers decline to hold their babies in en face position or to keep their babies at the foot of their beds in old disheveled clothes — these are deeply ingrained cultural practices that are at once harmless and understood to be beneficial to babies.

Kennell and Klaus have done much to promote the use of doulas to provide continuous emotional support in labor and thereby reduce both length of labor and the number of surgical and obstetrical interventions in birth.  They point out that doula-assisted births achieve a 25% reduction in the length of labor, greater than 50% reduction in cesarean deliveries and a substantial reduction in the use of oxytocin, medication, forceps and vacuum extractors.

Another important point they bring up in their discussion on how to measure bonding is that while it is helpful to parents and to society to examine a mother's or father's behavior with a baby, it is possible to be misled by such scrutiny.  In one hospital study in the United States that tested criteria for potentially abusive mothers, 30% of the new mothers were identified as potentially abusive.  However, follow-up of the mothers and their babies came up with no evidence of a parenting disorder.  "No reliable and simple test is available to distinguish parents who will abuse," they caution.

Much of Kennell and Klaus's most important writing has focused on the special area of bonding that emphasizes increasing mother-infant time together through simple, low-cost intervention in the first hours and days following birth.

Six of 9 studies showed that when a mother wants to breastfeed, is allowed early contact with her baby with a chance to suckle in the first hour of life, and is rooming-in with her baby, her chance of successfully starting breastfeeding is greatly improved, as is her chance of breastfeeding for longer than mothers who did not enjoy such early contact with their babies.

The studies of Brazelton and others have shown the positive benefits in mothering of such low-cost routines as nurses spending as little as 10 minutes helping mothers discover some of their babies' abilities, such as turning to the mother's voice or imitation, and helping mothers with suggestions about ways to quiet their babies.

Recent years have seen the publications of studies that provide ample evidence for an ability of newborns that have been largely unknown by medical professionals in the United States:  the ability, if left quietly, to crawl gradually up to the mother's breast, find the nipple, and start to suckle.  The human infant has been shown to be as talented at survival, given the proper circumstances, as its primate relatives.  Klaus and Kennell take note of the circumstances, as that should be promoted in order for this behavior to be likely:

• the mother has received no pain medication
• the baby is warm because it has been dried, placed on the mother's belly, covered and left for at least 60 minutes
• the mother's breasts are not washed.

Several important points, all of which are backed by plenty of evidence, emerge from this article:

• Continuous support by an experienced woman during labor results in a shorter labor, with a greater than 50% reduction in the need for obstetric interventions that may interfere with early mother-infant contact and interaction.
• Continuous labor support of the mother results in an increased incidence and duration of breastfeeding, more affectionate mother-infant contact, and psychological benefits.
• The crawling ability of the newborn infant, the sensitivity of the mother's nipple, the marked decrease in crying when the infant is skin-to-skin with the mother, and the warming abilities of the mother's chest are adaptive.
• When the infant suckles from the breast, there is an outpouring of 19 different gastrointestinal hormones in both the mother and the infant, including cholecystokinin and gastrin, which stimulate growth of the baby's and mother's intestinal villi, increasing the surface area and absorption of calories with each feeding.
• Encouraging mother-infant contact from birth on and rooming-in could increase breastfeeding significantly and decrease the incidence of failure to thrive, abuse, neglect, and abandonment of infants.