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Chapter 3 Birth and the Newborn Infant 105 Chapter Overview Birth Stillbirth and Infant Mortality: The Tragedy Labor: The Proc...

Chapter 3 Birth and the Newborn Infant 105 Chapter Overview Birth Stillbirth and Infant Mortality: The Tragedy Labor: The Process of Birth Begins of Premature Death Birth: From Fetus to Neonate Postpartum Depression: Moving from the Heights Approaches to Childbirth: Where Medicine of Joy to the Depths of Despair and Attitudes Meet The Competent Newborn Birth Complications Physical Competence: Meeting the Demands Preterm Infants: Too Soon, Too Small of a New Environment Postmature Babies: Too Late, Too Large Sensory Capabilities: Experiencing the World Cesarean Delivery: Intervening in the Process Early Learning Capabilities of Birth Social Competence: Responding to Others Prologue: Expecting the Unexpected Ariana Campo was all set for the birth of her daughter. Everything on her list was ticked off. Healthy diet. Low-impact pregnancy exercises. Childbirth class. But Ariana’s labor didn’t go quite the way she’d planned. Her water broke before her contractions started. In fact, her contractions didn’t start for another 12 hours, and they never became regular. When her cervix was dilated only 2 centimeters, she felt tremendous pressure to push. The nurse told her not to, but she didn’t tell her how, and Ariana found the breathing exercises she’d practiced for months to be completely useless. After 24 hours of labor, she was given an epidural procedure to relax her, but the drug and the exhaustion made it difficult to push effectively. When the baby’s heartbeat began dropping, the doctor used forceps. Ariana’s daughter was born within minutes, healthy and beautiful, but then a slight elevation in her temperature kept the baby in the neonatal unit for another week. Today, her daughter is a lively, curious toddler. “All’s well that ends well,” Ariana says, “but I learned that when it comes to childbirth, maybe it’s best to expect the unexpected.” Looking Ahead While labor and childbirth are generally less difficult than they were for Ariana Campo, all births are tinged with a combination of excitement and some degree of anxiety. In the vast majority of cases, however, delivery goes smoothly, and it is an amazing and joyous moment when a new being enters the world. The excitement of birth is soon replaced by wonder at the ­extraordinary nature of newborns themselves. Babies enter the world with a surprising array of capabilities, ready from the first moments of life outside the womb to respond to the world and the people in it. In this chapter, we’ll examine the events that lead to the delivery and birth of a child and take an initial look at the newborn. We first consider labor and delivery, exploring how the process usually pro- ceeds as well as several alternative approaches. We next examine some of the possible complica- tions of birth. The problems that can occur range from premature births to infant mortality. Finally, we consider the extraordinary range of capabilities of newborns. We’ll look not only at their physical and perceptual abil- ities, but at the way they enter the world with the ­ability to learn and with skills that help form the foundations of their future relationships with others. 106 PART 1 Beginnings Birth I wasn’t completely naïve. I mean, I knew that it was only in movies that babies come out of the womb all pink, dry, and beautiful. But still, I was initially taken aback by my son’s appearance. Because of his passage through the birth canal, his head was cone-shaped, a bit like a wet, partly deflated football. The nurse must have noticed my ­reaction because she hastened to assure me that all this would change in a matter of days. She then moved quickly to wipe off the whitish sticky substance all over his body, informing me as she did so that the fuzzy hair on his ears was only temporary. I leaned in and put my finger into my boy’s hand. He rewarded me by closing his hand around it. I interrupted the nurse’s assurances. “Don’t worry,” I stammered, tears suddenly filling my eyes. “He’s absolutely the most beautiful thing I’ve ever seen.” For those of us accustomed to thinking of newborns in the images of baby food com- mercials, this portrait of a typical newborn may be surprising. Yet most babies come out of the womb resembling this one. Make no mistake, however: Despite their tem- porary blemishes, babies are a welcome sight to their parents from the moment of their birth. The newborn’s outward appearance is caused by a variety of factors in its journey from the mother’s uterus, down the birth canal, and out into the world. We can trace its passage, beginning with the release of the chemicals that initiate the process of l­ abor. Labor: The Process of Birth Begins LO 3.1 Describe the normal process of labor. About 266 days after conception, a protein called corticotropin-releasing hormone (CRH) triggers (for some still unknown reason) the release of various hormones, and the pro- cess that leads to birth begins. One critical hormone is oxytocin, which is released by the mother’s pituitary gland. When the concentration of oxytocin becomes high enough, the mother’s uterus begins periodic contractions (Hertelendy & Zakar, 2004; Terzidou, 2007; ­Tattersall et al., 2012). During the prenatal period, the uterus, which is composed of muscle tissue, slowly ­expands as the fetus grows. Although for most of the pregnancy it is inactive, after the fourth month it occasionally contracts in order to ready itself for the eventual delivery. These contractions, called Braxton–Hicks contractions, are sometimes called “false labor,” neonates because while they can fool eager and anxious expectant parents, they do not signify that the term used for newborns the baby will be born soon. When birth is actually imminent, the uterus begins to contract intermittently. The increasingly intense contractions make the uterus act like a vise, opening and closing to force the head of the fetus against the cervix, the neck of the uterus that separates it from the vagina. E ­ ventually, the force of the contractions becomes strong enough to pro- pel the fetus slowly down the birth canal until it enters the world as a neonate—the term used for a newborn. It is this exertion and the narrow birth passageway that often gives newborns the battered, cone-head appearance described earlier. Labor proceeds in three stages (see Figure 3-1). In the first stage of labor, the uterine contractions initially occur around every 8 to 10 minutes and last about 30 seconds. As labor proceeds, the contractions occur more frequently and last longer. Toward the end of labor, the contractions may occur every 2 minutes and last almost 2 minutes. Labor can be exhausting and seems never ending, but support, During the final part of the first stage of labor, the contrac- ­communication, and a willingness to try different techniques can all be tions increase to their ­greatest intensity, a period known helpful. as ­transition. The mother’s cervix fully opens, eventually  Chapter 3 Birth and the Newborn Infant 107 Figure 3-1 The Three Stages of Labor Stage 1 Stage 2 Stage 3 Umbilical cord Uterus Cervix Placenta Placenta Uterine contractions initially occur every 8 to The baby's head starts to move through The child's umbilical cord (still attached to the 10 minutes and last 30 seconds. Toward the the cervix and birth canal. Typically neonate) and the placenta are expelled from end of labor, contractions may occur every 2 lasting around 90 minutes, the second the mother. This stage is the quickest and minutes and last as long as 2 minutes. As stage ends when the baby has completely easiest, taking just a few minutes. the contractions increase, the cervix, which left the mother's body. separates the uterus from the vagina, becomes wider, eventually expanding to allow the baby's head to pass through. e­ xpanding enough (usually to around 10 centimeters) to allow the baby’s head (the wid- est part of the body) to pass through. This first stage of labor is the longest. Its duration varies significantly, depending on the mother’s age, race, ethnicity, number of prior pregnancies, and a variety of other factors involving both the fetus and the mother. Typically, labor takes 16 to 24 hours for firstborn children, but there are wide variations. Births of subsequent c­ hildren usually involve shorter periods of labor. During the second stage of labor, which typically lasts around 90 minutes, the b ­ aby’s head emerges further from the mother with each contraction, increasing the size of the vag- inal opening. Because the area between the vagina and rectum must stretch a good deal, an incision called an episiotomy is sometimes made to increase the size of the opening of the episiotomy vagina. However, this practice has been increasingly criticized in recent years as potentially an incision sometimes made to causing more harm than good, and the number of episiotomies has fallen drastically in the increase the size of the opening last decade (Graham et al., 2005; Dudding, Vaizey, & Kamm, 2008; Manzanares et al., 2013). of the vagina to allow the baby The second stage of labor ends when the baby has completely left the mother’s body. to pass Finally, the third stage of labor occurs when the child’s umbilical cord (still attached to the neonate) and the placenta are expelled from the mother. This stage is the ­quickest and easiest, taking just a few minutes. A woman’s reactions to labor reflect, in part, cultural factors. WATCH THIS VIDEO ON MYPSYCHLAB LABOR Although there is no evidence that the physiological aspects of la- bor differ among women of different cultures, expectations about labor and interpretations of its pain do vary significantly from one culture to another (Callister et al., 2003; Fisher, Hauck, & Fenwick, 2006; Steel et al., 2014). For instance, there is a kernel of truth to popular stories of pregnant women in certain societies putting down the tools with which they are tilling their fields, stepping aside and giving birth, and immediately returning to work with their neonates wrapped and bundled on their backs. Accounts of the !Kung people in ­Africa describe the woman in labor sitting calmly beside a tree and ­without much ado—or ­assistance—successfully giving birth to a child and quickly recovering. On the other hand, many societies regard childbirth as dangerous, and some even view it in terms 108 PART 1 Beginnings Are You an Informed Consumer of Development? Dealing with Labor Every woman who is soon to give birth has some fear of labor. only another 20 minutes or so, you may feel you can Most have heard gripping tales of extended, 48-hour labors or handle it. vivid descriptions of the pain that accompanies labor. Still, few Remember that labor is … laborious. Expect that you mothers would dispute the notion that the rewards of giving may become fatigued, but realize that as the final stages birth are worth the effort. of labor occur, you may well get a second wind. There is no single right or wrong way to deal with labor. Accept your partner’s support. If a spouse or other However, several strategies can help make the process as partner is present, allow that person to make you positive as possible: comfortable and provide support. Research has shown that women who are supported by a spouse or partner Be flexible. Although you may have carefully worked have a more comfortable birth experience (Bader, 1995; out what to do during labor, don’t feel an obligation to Kennell, 2002). follow through exactly. If a strategy is ineffective, turn to Be realistic and honest about your reactions to pain. another one. Even if you had planned an unmedicated delivery, realize Communicate with your health-care providers. Let that you may find the pain difficult to tolerate. At that point, them know what you are experiencing. They may be able consider the use of drugs. Above all, don’t feel that asking to suggest ways to deal with what you are encountering. for pain medication is a sign of failure. It isn’t. As your labor progresses, they may also be able to give Focus on the big picture. Keep in mind that labor is part you a fairly clear idea of how much longer you will be in of a process that ultimately leads to an event unmatched labor. Knowing the worst of the pain is going to last in the joy it can bring. ­ efitting an illness. Such cultural perspectives color the way that people in a given soci- b ety view the experience and e­ xpectations about dealing with childbirth, as we d ­ iscuss in the Are You an Informed C ­ onsumer of Development? section. Birth: From Fetus to Neonate LO 3.2 Explain the events that occur in the first few hours of a newborn’s life. The exact moment of birth occurs when the fetus, having left the uterus through the ­cervix, passes through the vagina to emerge fully from its mother’s body. In most cases, babies automatically make the transition from taking in oxygen via the placenta to using their lungs to breathe air. Consequently, as soon as they are outside the mother’s body, most newborns spontaneously cry. This helps them clear their lungs and breathe on their own. What happens next varies from situation to situation and from culture to culture. In Western cultures, health-care workers are almost always on hand to assist with the birth. In the United States, 99 percent of births are attended by professional health-care workers, but in many less-developed countries less than half of births have ­professional health-care workers in attendance (United Nations Statistics Division, 2012). THE APGAR SCALE. In most cases, the newborn infant first undergoes a quick visual inspection. Parents may be counting fingers and toes, but trained health-care w ­ orkers look Apgar scale for something more. Typically, they employ the Apgar scale, a standard measurement a standard measurement system that looks for a variety of indications of good health (see Table 3-1). D ­ eveloped by system that looks for a variety physician Virginia Apgar, the scale directs attention to five basic qualities, recalled most of indications of good health in easily by using Apgar’s name as a guide: appearance (color), pulse (heart rate), grimace newborns (reflex irritability), activity (muscle tone), and respiration (respiratory ­effort). Using the scale, health-care workers assign the newborn a score ranging from 0 to 2 on each of the five qualities, producing an overall score that can range from 0 to 10. The vast ma- jority of children score 7 or above. The 10 percent of neonates who score under 7 require help to start breathing. Newborns who score under 4 need immediate, life-saving intervention.  Chapter 3 Birth and the Newborn Infant 109 Table 3-1 Apgar Scale A score is given for each sign at 1 minute and 5 minutes after the birth. If there are problems with the baby, an additional score is given at 10 minutes. A score of 7 to 10 is considered normal, whereas 4 to 7 might require some resuscitative measures, and a baby with an Apgar score under 4 requires immediate resuscitation. Sign 0 Points 1 Point 2 Points A Appearance (skin color) Blue-gray, Normal, except for Normal over entire body pale all over extremities P Pulse Absent Below 100 bpm Above 100 bpm G Grimace (reflex irritability) No response Grimace Sneezes, coughs, pulls away A Activity (muscle tone) Absent Arms and legs flexed Active movement R Respiration Absent Slow, irregular Good, crying (Source: Apgar, 1953.) Low Apgar scores (or low scores on other neonatal assessments, such as the ­Brazelton Neonatal Behavioral Assessment Scale, which we discuss in Chapter 4) may indicate prob- lems or birth defects that were already present in the fetus. However, the process of birth itself may sometimes cause difficulties. Among the most profound are those relating to a temporary deprivation of oxygen. At various junctures during labor, the fetus may lack sufficient oxygen. This can hap- pen for any of a number of reasons. For instance, the umbilical cord may get wrapped around the neck of the fetus. The cord can also be pinched during a ­prolonged contrac- tion, thereby cutting off the supply of oxygen that flows through it. Lack of oxygen for a few seconds is not harmful to the fetus, but deprivation for any longer may cause serious harm. A restriction of oxygen, or anoxia, lasting a few minutes anoxia can produce cognitive deficits such as language delays and even mental ­retardation due a restriction of oxygen to the baby, to brain cell death (Rossetti, Carrera, & Oddo, 2012; Stecker, Wolfe, & Stevenson, 2013; lasting a few minutes during the Hynes, Fish, & Manly, 2014). birth process, that can produce brain damage NEWBORN MEDICAL SCREENING. Just after birth, newborns typically are tested for a variety of diseases and genetic conditions. The American College of Medical Genet- ics recommends that all newborns be screened for 29 disorders, ranging from hearing difficulties and sickle-cell anemia to extremely rare conditions such as isovaleric acidemia, a disorder involving metabolism. These disorders can be detected from a tiny quantity of blood drawn from an infant’s heel (American College of Medical Genetics, 2006). The advantage of newborn screening is that it permits early treatment of ­problems that might go undetected for years. In some cases, devastating ­conditions can be prevented through early treatment of the disorder, such as the ­implementation of a particular kind of diet (Goldfarb, 2005; Kayton, 2007; Timmermans & Buchbinder, 2012). The exact number of tests that a newborn experiences varies drastically from state to state. In some states, only three tests are mandated, while in oth- ers over 30 are required. In jurisdictions with only a few tests, many disorders go undiagnosed. In fact, each year around 1,000 infants in the United States suffer from disorders that could have been detected at birth if ­appropriate screening had been conducted. PHYSICAL APPEARANCE AND INITIAL ENCOUNTERS. In addition to assessing the newborn’s health, health-care workers deal with the remnants of the child’s passage through the birth canal. You’ll recall the description of the thick, greasy substance (like cottage cheese) that covers the newborn. This The perfect image of newborns portrayed in material, called vernix, smoothes the p­ assage through the birth canal; it is no commercials, television programs, and movies longer needed once the child is born and is quickly cleaned away. Newborns’ differs dramatically from reality. 110 PART 1 Beginnings bodies are sometimes covered with a fine, dark fuzz known as lanugo that soon disap- pears. The newborn’s eyelids may be puffy due to an accumulation of fluids during la- bor, and the newborn may have blood or other fluids on parts of its body. After being cleansed, the newborn is usually returned to the mother and, if he is present, the father. The importance of this initial encounter between parent and child has become a matter of considerable controversy. Some psychologists and physicians ar- bonding gued that bonding, the close physical and emotional contact between parent and child close physical and emotional during the period immediately following birth, was a crucial ingredient for forming contact between parent and child a lasting relationship between parent and child (Lorenz, 1957). Their arguments were during the period immediately based in part on research conducted on nonhuman species such as ducklings. This work following birth, argued by some to showed that there was a critical period just after birth when organisms showed a par- affect later relationship strength ticular readiness to learn, or imprint, from other members of their species who hap- pened to be present. According to the concept of bonding applied to humans, a critical ­period begins just after birth and lasts only a few hours. During this period, actual skin-to-skin contact be- tween mother and child supposedly leads to deep, emotional bonding. The corollary to this assumption is that if circumstances prevent such contact, the bond between mother and child will ­forever be lacking in some way. Because so many babies were taken from their mothers and placed in incubators or in the hospital nursery, medical practices often left little opportunity for sustained mother and child physical contact immediately after birth. When developmental researchers carefully reviewed the research ­literature, how- ever, they found little support for the existence of a critical p­ eriod for bonding at birth. Although it does appear that mothers who have early physical contact with their babies are more responsive to them than those who don’t have such contact, the difference lasts only a few days. Such news is reassuring to parents whose children must receive im- mediate, intensive medical attention just after birth. It is also comforting to parents who adopt children and are not present at their births (Miles et al., 2006; Bigelow & Power, 2012; Hall et al., 2014). Although immediate mother–child bonding does not seem critical, it is important for newborns to be gently touched and massaged soon a­ fter birth. The physical stimulation they receive leads to the production of chemicals in the brain that instigate growth. C ­ onsequently, infant massage is related to weight gain, better sleep–waking patterns, better neuromotor development, and reduced rates of infant mortality (Field, 2001; Kulkarni et al., 2011; van Reenen & van Rensburg, 2013). Approaches to Childbirth: Where Medicine and Attitudes Meet LO 3.3 Describe some of the current approaches to childbirth. In her second pregnancy, Alma Juarez knew she wanted something other than ­traditional obstetrics. No drugs. No lying f lat on her back for the de- livery (which had slowed her contractions and made an oxygen mask neces- sary). This time, Juarez took control. She joined an exercise class for pregnant women and read books on childbirth. She also chose a nurse-midwife instead of an obstetrician. She wanted someone to work with her, not dictate to her. When Juarez went into labor, she called the midwife, who met her at the hospital. Juarez was determined to stay on her feet, making use of gravity to hasten the birth. Her husband and the midwife took turns walking with her as the contractions got stronger. When she was fully dilated, she got on her hands and knees, a posture she knew would minimize the effort of pushing. Although the observation of nonhuman animals Thirty minutes later, her daughter was born. No drugs, no extra oxygen. highlights the importance of contact between Juarez says, “The first birth, I was exhausted. The second birth, I was elated.” mother and offspring following birth, research on humans suggests that immediate physical contact Parents in the Western world have developed a variety of strategies—and is less critical. some very strong opinions—to help them deal with something as natural as  Chapter 3 Birth and the Newborn Infant 111 giving birth, which occurs apparently without much thought throughout the nonhuman animal world. Today parents need to make a number of decisions. Should the birth take place in a hospital or in the home? Should a physician, a nurse, or a mid- wife assist? Is the father’s presence desirable? Should siblings and other family members be on hand to participate in the birth? Most of these questions cannot be answered definitively, pri- marily because the choice of childbirth techniques often comes down to a matter of values and opinions. No single procedure will be effective for all mothers and fathers, and no conclusive research evidence has proven that one procedure is significantly more effective than another. As we’ll see, there is a wide vari- ety of different issues and options involved, and certainly one’s ­culture plays a role in choices of birthing procedures. The abundance of choices is largely due to a reaction to tra- ditional medical practices that had been common in the United States until the early 1970s. Before that time, the typical birth went something like this: A woman in labor was placed in a room with many other women, all of whom were in various stages of childbirth and some of whom were screaming in pain. Fathers and other family members were not allowed to be pres- ent. Just before delivery, the woman was rolled into a delivery room, where the birth took place. Often she was so drugged that she was not aware of the birth at all. At the time, physicians argued that such procedures were necessary to ensure the health of the newborn and the mother. However, critics charged that alternatives were available that not only would maximize the medical well-being of the par- ticipants in the birth but also would represent an emotional Some women choose to use a midwife to assist them in their and psychological improvement (Curl et al., 2004; Hotelling & pregnancy and delivery. ­Humenick, 2005). ALTERNATIVE BIRTHING PROCEDURES. Not all mothers give birth in hospitals, and not all births follow a traditional course. Among the major alternatives to t­ raditional birthing practices are the following: Lamaze birthing techniques. The Lamaze method has achieved widespread popular- ity in the United States. Based on the writings of Dr. Fernand Lamaze, the method makes use of breathing techniques and relaxation training (­Lamaze, 1970). Typically, mothers-to-be participate in a series of weekly training sessions in which they learn exercises that help them relax various parts of the body on command. A “coach,” most typically the father, is trained along with the future mother. The training allows women to cope with painful contractions by concentrating on their breathing and producing a relaxation response, rather than by tensing up, which can make the pain more acute. Women learn to focus on a relaxing stimulus, such as a tranquil scene in a picture. The goal is to learn how to deal positively with pain and to relax at the onset of a ­contraction (Lothian, 2005). Does the procedure work? Most mothers, as well as fathers, report that a ­Lamaze birth is a very positive experience. They enjoy the sense of mastery that they gain over the process of labor, a feeling of being able to exert some control over what can be a formidable experience. On the other hand, we can’t be sure that parents who choose the Lamaze method aren’t already more highly motivated about the experience of childbirth than parents who do not choose the technique. It is there- fore possible that the accolades they express after Lamaze births are due to their ini- tial enthusiasm and not to the Lamaze procedures themselves (Larsen et al., 2001; Zwelling, 2006). 112 PART 1 Beginnings Participation in Lamaze procedures—as well as other natural childbirth t­ echniques in which the emphasis is on educating the parents about the process of birth and minimizing the use of drugs—is relatively rare among members of lower- income groups, including many members of ethnic minorities. Parents in these groups may not have the transportation, time, or financial resources to ­attend child- birth preparation classes. The result is that women in lower-income groups tend to be less prepared for the events of labor and consequently may ­suffer more pain dur- ing childbirth (Brueggemann, 1999; Lu et al., 2003). Bradley method. The Bradley method, which is sometimes known as “husband- coached childbirth,” is based on the principle that childbirth should be as natural as possible and involve no medication or medical interventions. Women are taught to “tune into” their bodies in order to deal with the pain of childbirth. To prepare for childbirth, mothers-to-be are taught muscle relaxation techniques, similar to Lamaze procedures, and good nutrition and exercise during pregnancy are seen as important to prepare for delivery. Parents are urged to take responsibility for childbirth, and the use of physicians is viewed as unnecessary and sometimes even dangerous. As you might expect, the discouragement of traditional medical inter- ventions is quite controversial (McCutcheon-Rosegg, Ingraham, & Bradley, 1996; Reed, 2005). Hypnobirthing. Hypnobirthing is a new, but increasingly popular, technique. It in- volves a form of self-hypnosis during delivery that produces a sense of peace and calm, thereby reducing pain. The basic concept is to produce a state of ­focused con- centration in which a mother relaxes her body while focusing inward. Increasing re- search evidence shows the technique can be effective in reducing pain (­ Olson, 2006; White, 2007; Alexander, Turnball, & Cyna, 2009). Water Birthing. Still relatively uncommon in the United States, water ­birthing is a practice in which a woman enters a pool of warm water to give birth. The theory is that the warmth and buoyancy of the water is soothing, easing the length and pain of labor and childbirth, and the entry into the world is soothed for the infant, who moves from the watery environment of the womb to the birthing pool. Although there is some evidence that water birthing reduces pain and the length of labor, there is a risk of infection from the unsterile water (Thöni, Mussner, & Ploner, 2010; Jones et al., 2012). C H I L D B I R T H AT T E N D A N T S : W H O ­DELIVERS? Traditionally, obstetricians, physi- cians who specialize in delivering b­ abies, have been the childbirth attendants of choice. In the last few decades, more mothers have chosen to use a midwife, a childbirth attendant who stays with the mother throughout labor and delivery. Midwives—most often nurses specializing in childbirth—are used primarily for pregnancies in which no complications are expected. The use of midwives has increased steadily in the United States—there are now 7,000 of them— and they are employed in 10 percent of births. Midwives help deliver some 80 percent of ba- bies in other parts of the world, often at home. Home birth is common in countries at all levels of economic development. For instance, a third of all births in the Netherlands occur at home With water birthing, the woman enters a pool of warm water to give birth. (Ayoub, 2005; Klein, 2012; Sandall, 2014).  Chapter 3 Birth and the Newborn Infant 113 From a health-care worker’s perspective While 99 percent of U.S. births are attended by professional medical workers or birthing attendants, this is the case in only about half of births worldwide. What do you think are some reasons for this, and what are the implications of this statistic? The newest trend in childbirth assistance is also one of the oldest: the doula (­pronounced doo-lah). A doula is trained to provide emotional, psychological, and edu- cational support during birth. A doula does not replace an obstetrician or midwife, and does not do medical exams. Instead, doulas, who are often well-versed in ­birthing alter- natives, provide the mother with support and make sure parents are aware of alterna- tives and possibilities regarding the birth process. Although the use of doulas is new in the United States, they represent a return to an older tradition that has existed for centuries in other cultures. Although they may not be called “doulas,” supportive, experienced older women have helped mothers as they give birth in non-Western cultures for centuries. A growing body of research indicates that the presence of a doula is beneficial to the birth process, speeding deliveries and reducing reliance on drugs. Yet concerns remain about their use. Unlike certified midwives, who are nurses and receive an a­ dditional year or two of training, doulas do not need to be certified or have any p ­ articular level of edu- cation (Mottl-Santiago et al., 2008; Humphries, & Korfmacher, 2012; Simkin, 2014). PAIN AND CHILDBIRTH. Any woman who has delivered a baby will agree that child- birth is painful. But how painful, exactly, is it? Such a question is largely unanswerable. One reason is that pain is a subjective, psy- chological phenomenon, one that cannot be easily measured. No one is able to a­ nswer the question of whether their pain is “greater” or “worse” than someone else’s pain, al- though some studies have tried to quantify it. For instance, in one survey women were asked to rate the pain they experienced during labor on a 1 to 5 scale, with 5 being the most painful (Yarrow, 1973). Nearly half (44 percent) said “5,” and an additional one- quarter said “4.” Because pain is usually a sign that something is wrong in one’s body, we have learned to react to pain with fear and concern. Yet during childbirth, pain is actually a signal that the body is working appropriately—that the contractions that are meant to propel the baby through the birth canal are doing their job. Consequently, the experi- ence of pain during labor is difficult for women in labor to interpret, thereby p­ otentially increasing their anxiety and making the contractions seem even more painful. Ultimately, every woman’s delivery depends on such variables as how much preparation and sup- port she has before and during delivery, her culture’s view of pregnancy and delivery, and the specific nature of the delivery itself (Ip, Tang, & G­ oggins, 2009; de C. Williams et al., 2013; Karlsdottir, Halldorsdottir & Lundgren, 2014). USE OF ANESTHESIA AND PAIN-REDUCING DRUGS. Among the greatest ­advances of modern medicine is the ongoing discovery of drugs that reduce pain. However, the use of medication during childbirth is a practice that holds both benefits and pitfalls. About a third of women who receive anesthesia do so in the form of epidural ­anesthesia, which produces numbness from the waist down. Traditional epidurals pro- duce an inability to walk and in some cases prevent women from helping to push the baby out during delivery. However, a newer form of epidural, known as a walking ­epidural or dual spinal–epidural, uses smaller needles and a system for administering continuous doses of anesthetic. It permits women to move about more freely during labor and has fewer side effects than traditional epidural anesthesia (Simmons et al., 2007). It is clear that drugs hold the promise of greatly reducing, and even eliminating, pain associated with labor, which can be extreme and exhausting. However, pain ­reduction is 114 PART 1 Beginnings not without potential costs, because the drugs may affect the fetus and newborn by de- creasing physiological responsiveness in the newborn. The stronger the drug, the greater the potential effects. Still, most research suggests that drugs, as they are currently employed during labor, produce only minimal risks to the fetus and neonate. Guidelines issued by the American College of Obstetricians and Gynecologists suggest that a woman’s request for pain relief at any stage of labor should be honored and that the proper use of minimal amounts of drugs for pain relief is reasonable and has no significant effect on a child’s later well- being (ACOG, 2002; Alberts et al., 2007; Costa-Martins et al., 2014). POSTDELIVERY HOSPITAL STAY: DELIVER, THEN DEPART? When New Jersey mother Diane Mensch was sent home from the hospital just a day after the birth of her third child, she still felt exhausted. But her insurance company insisted that 24 hours was sufficient time to recover, and it refused to pay for more. Three days later, her new- born was back in the hospital, suffering from jaundice. Mensch is convinced the problem would have been discovered and treated sooner had she and her newborn been allowed to remain in the hospital longer (Begley, 1995). Mensch’s experience is not unusual. In the 1970s, the average hospital stay for a normal birth was 3.9 days. By the 1990s, it was 2 days. These changes were prompted in large part by medical insurance companies, who advocated hospital stays of only 24 hours following birth in order to reduce costs. Medical care providers have fought against this trend, believing that there are definite risks involved, both for mothers and for their newborns. For instance, mothers may begin to bleed if they tear tissue injured during childbirth. It is also riskier for newborns to be discharged prematurely from the sophisticated medi- cal care that hospitals can provide. Furthermore, moth- ers are better rested and more satisfied with their medical care when they stay longer (Finkelstein, Harper, & Rosenthal, 1998). In accordance with these views, the American Acad- emy of Pediatrics states that women should stay in the hospital no less than 48 hours after giving birth, and the U.S. Congress has passed legislation mandating a minimum insurance coverage of 48 hours for childbirth Mothers who spend more time in the hospital following the birth of a child (American Academy of Pediatrics Committee on Fetus do better than those discharged after a shorter period. and ­Newborn, 2004). Module 3.1 Review In the first stage of labor, contractions increase in frequency, Many birthing options are available to parents today. They may duration, and intensity until the baby’s head is able to pass use a midwife or doula in addition to or instead of an obstetrician, through the cervix. In the second stage, the baby moves and they may weigh the advantages and disadvantages of through the cervix and birth canal and leaves the mother’s anesthetic drugs during birth. Some women choose alternatives body. In the third stage, the umbilical cord and placenta to traditional hospital birthing, including the Lamaze method, the emerge. Bradley method, hypnobirthing, and water birthing. Immediately after birth, birthing attendants usually examine the neonate using a measurement system such as the Apgar scale. Newborns are also typically tested for a variety of Journal Writing Prompt diseases and genetic conditions. The newborn is usually Applying Lifespan Development: Birthing practices in the returned to its parents shortly after birth so that they may United States have changed considerably since the 1970s. hold and bond with the baby. Describe any changes that have taken place in your country.  Chapter 3 Birth and the Newborn Infant 115 Birth Complications When Ivy Brown’s son was stillborn, a nurse told her that sad as it was, nearly 1 percent of births in her city, Washington, D.C., ended in death. That statistic spurred Brown to become a grief counselor, specializing in infant mortality. She formed a commit- tee of physicians and city officials to study the capital’s high infant mortality rate and find solutions to lower it. “If I can spare one mother this terrible grief, my loss will not be in vain,” Brown says. The infant mortality rate in the United States, the richest country in the world, is 6.17 deaths per 1,000 live births. Some wealthy countries, such as Japan, have an infant mortality rate that is half of that in the United States. Overall, nearly 50 countries have better birth rates than the United States (The World Factbook, 2012; Sun, 2012; see Figure 3-2). Why is infant survival less likely in the United States than in quite a few less ­developed countries? To answer this question, we need to consider the nature of the problems that can occur during labor and delivery. Figure 3-2 International Infant Mortality Infant mortality rates in selected countries. Although the United States has greatly reduced its infant mortality rate in the past 25 years, it ranks only twenty-third among industrialized countries as of 2010. What are some of the reasons for this? (Source: The World Factbook, 2010.) Singapore Sweden Japan Hong Kong France Finland Norway Czech Republic Germany Spain Israel Denmark Belgium Australia Portugal United Kingdom New Zealand Canada Ireland Greece Italy Cuba United States Poland Slovakia Hungary Costa Rica Kuwait Russia Romania 0 5 10 15 20 25 Number of Deaths per Thousand 116 PART 1 Beginnings Preterm Infants: Too Soon, Too Small LO 3.4 Describe some of the causes of, effects of, and treatments for preterm births. preterm infants Around one out of ten infants are born earlier than normal. Preterm infants, or prema- infants who are born prior to ture infants, are born prior to 38 weeks after conception. Because they have not had time 38 weeks after conception (also to develop fully as fetuses, preterm infants are at high risk for illness and death. known as premature infants) The extent of danger faced by preterm babies largely depends on the child’s weight at birth, which has great significance as an indicator of the extent of the b ­ aby’s develop- ment. Although the average newborn weighs around 3,400 grams (about 7 1/2 pounds), low-birthweight infants low-birthweight infants weigh less than 2,500 grams (around 5 1/2 pounds). Only 7 infants who weigh less than percent of all newborns in the United States fall into the low-­birthweight category, but 2,500 grams (around 5 1/2 pounds) they account for the majority of newborn deaths (Gross, Spiker, & Haynes, 1997; DeVader at birth et al., 2007). Although most low-birthweight infants are preterm, some are small-for-­gestational- small-for-gestational-age infants age babies. Small-for-gestational-age infants are infants who, because of delayed fetal infants who, because of growth, weigh 90 percent (or less) of the average weight of infants of the same gesta- delayed fetal growth, weigh 90 tional age. Small-for-gestational-age infants are sometimes also preterm, but may not be. percent (or less) of the average The syndrome may be caused by inadequate nutrition during p ­ regnancy (Bergmann, weight of infants of the same Bergmann, & Dudenhausen, 2008; Salihu et al., 2013). gestational age If the degree of prematurity is not too great and weight at birth is not extremely low, the threat to the child’s well-being is relatively minor. In such cases, the main treatment may be to keep the baby in the hospital to gain weight. Additional weight is critical be- cause fat layers help prevent chilling in neonates, who are not particularly efficient at regulating body temperature. Research also shows that preterm infants who receive more responsive, stimulating, and organized care are apt to show more positive outcomes than those children whose care is not as good. Some of these interventions are quite simple. For example, “Kangaroo Care,” in which infants are held skin-to-skin against their parents’ chests, appears to be ef- fective in helping preterm infants develop. Massaging preterm infants several times a day triggers the release of hormones that promote weight gain, muscle development, and abili- ties to cope with stress (Field et al., 2008; Kaffashi et al., 2013; Athanasopoulou & Fox, 2014). Newborns who are born more prematurely and who have birthweights significantly below average face a tougher road. For them, simply staying alive is a ­major task. For instance, low-birthweight infants are highly vulnerable to infection, and ­because their lungs have not had sufficient time to develop completely, they have problems taking in sufficient oxygen. As a consequence, they may experience ­respiratory distress syndrome (RDS), with potentially fatal consequences. To deal with respiratory distress syndrome, low-birth- weight infants are often placed in incubators, enclosures in which temperature and oxygen content are controlled. The exact amount of oxygen is carefully monitored. Too low a concentration of oxygen will not provide relief, and too high a concentration can damage the delicate retinas of the eyes, leading to permanent blindness. The immature development of preterm neonates makes them unusually sensitive to stimuli in their envi- ronment. They can easily be overwhelmed by the sights, sounds, and sensations they experience, and their breath- ing may be interrupted or their heart rates may slow. They are often unable to move smoothly; their arm and leg movements are uncoordinated, causing them to jerk about and appear startled. Such behavior is quite disconcerting Preterm infants stand a much greater chance of survival today than they to parents (Doussard-Roosevelt et al., 1997; Miles et al., did even a decade ago. 2006; Valeri et al., 2014).  Chapter 3 Birth and the Newborn Infant 117 Despite the difficulties they experience at birth, the majority of preterm infants eventually develop normally in the long run. However, the tempo of development of- ten proceeds more slowly for preterm children compared to children born at full term, and more subtle problems sometimes emerge later. For example, by the end of their first year, only 10 percent of prematurely born infants display significant problems, and only 5 percent are seriously disabled. By the age of 6, however, a­ pproximately 38 percent have mild problems that call for special educational ­interventions. For instance, some preterm children show learning disabilities, b ­ ehavior disorders, or lower-than-average IQ scores. They also may be at greater risk for mental illness. Others have difficulties with physical coordination. Still, around 60 percent of preterm infants are free of even minor problems (Dombrowski, Noonan, & Martin, 2007; Hall et al., 2008; Nosarti et al., 2012). VERY-LOW-BIRTHWEIGHT INFANTS: THE SMALLEST OF THE SMALL. The story is less positive for the most extreme cases of prematurity—very-low-birthweight infants. Very-low-birthweight infants weigh less than 1,250 grams (around 2 1/4 pounds) or, very-low-birthweight infants ­regardless of weight, have been in the womb less than 30 weeks. infants who weigh less than 1,250 Very-low-birthweight infants not only are tiny—some fitting easily in the palm of grams (around 2.25 pounds) or, the hand at birth—they hardly seem to belong to the same species as full-term newborns. regardless of weight, have been in Their eyes may be fused shut and their earlobes may look like flaps of skin on the sides of the womb less than 30 weeks their heads. Their skin is a darkened red color, whatever their race. Very-low-birthweight babies are in grave danger from the moment they are born, due to the immaturity of their organ systems. Before the mid-1980s, these babies would not have survived outside their mothers’ wombs. However, medical advances have led to a higher chance of survival, pushing the age of viability, the point at which an infant can survive prematurely, to about 22 weeks—some 4 months earlier than the term of a normal delivery. Of course, the longer the period of development beyond conception, the higher are a newborn’s chances of survival. A baby born earlier than 25 weeks has less than a 50– 50 chance of survival (see Figure 3-3; Seaton et al., 2012). As medical capabilities progress and developmental researchers come up with new strategies for dealing with preterm infants and improving their lives, the age of v ­ iability is likely to be pushed even earlier. The physical and cognitive problems experienced by low-birthweight and p ­ reterm babies are even more pronounced in very-low-birthweight infants, with a­ stonishing ­financial consequences. A three-month stay in an incubator in an intensive-care unit can run hundreds of thousands of dollars, and about half of these newborns ultimately die, despite massive medical intervention (Taylor et al., 2000). Figure 3-3 Survival and Gestational Age Chances of a fetus surviving greatly improve after 28 to 32 weeks. Rates shown are the number per thousand of babies born in the United States after specified lengths of gestation who survive the first year of life. United Austria Denmark England Finland Northern Norway Poland Scotland Sweden States and Wales2 Ireland 22–23 707.7 888.9 947.4 880.5 900.0 1,000.0 555.6 921.1 1,000.0 515.2 weeks1 24–27 236.9 319.6 301.2 298.2 315.8 268.3 220.2 530.6 377.0 197.7 weeks 28–31 45.0 43.8 42.2 52.2 58.5 54.5 56.4 147.7 60.8 41.3 weeks 32–36 8.6 5.8 10.3 10.6 9.7 13.1 7.2 23.1 8.8 12.8 weeks 37 weeks 2.4 1.5 2.3 1.8 1.4 1.6 1.5 2.3 1.7 1.5 or more 1 Infant mortality rates at 22–23 weeks of gestation may be unreliable due to reporting differences. 2 England and Wales provided 2005 data. NOTE: Infant mortality rates are per 1,000 live births in specified group. SOURCE: NCHS linked birth/infant death data set (for U.S. data), and European Perinatal Health Report (for European data). (Source: Based on MacDorman & Mathews, 2009.) 118 PART 1 Beginnings Even if a very-low-birthweight preterm infant survives, the medical costs can continue to mount. For instance, one estimate suggests that the average monthly cost of medical care for such infants during the first 3 years of life may be between 3 and 50 times higher than the medical costs for a full-term child. Such astronomical costs have raised ethical de- bates about the expenditure of substantial financial and human resources in cases in which a positive outcome may be unlikely (Prince, 2000; Doyle, 2004; Petrou, 2006). WHAT CAUSES PRETERM AND LOW-BIRTHWEIGHT DELIVER- WATCH THIS VIDEO ON MYPSYCHLAB IES? About half of preterm and low-birthweight births are unex- PREMATURE BIRTH AND THE NEONATAL INTENSIVE CARE UNIT plained, but several known causes account for the remainder. In some cases, premature labor results from difficulties relating to the moth- er’s reproductive system. For instance, mothers carrying twins have unusual stress placed on them, which can lead to early labor. In fact, most multiple births are preterm to some degree (Luke & Brown, 2008; Saul, 2009; Habersaat et al., 2014). In other cases, preterm and low-birthweight babies are a result of the immaturity of the mother’s reproductive system. Young mothers— under the age of 15—are more prone to deliver prematurely than older ones. In addition, a woman who becomes pregnant within 6 months of her previous pregnancy and delivery is more likely to deliver a preterm or low-birthweight infant than a woman whose reproductive system has had a chance to recover from a prior delivery. The father’s age matters, too: Wives of older fathers are more likely to have preterm deliveries (Smith et al., 2003; Zhu & Weiss, 2005; Branum, 2006). Finally, factors that affect the general health of the mother, such as nutrition, level of medical care, amount of stress in the environment, and economic support, all are re- lated to prematurity and low birthweight. Rates of preterm births differ between ­racial groups, not because of race per se but because members of racial minorities have dis- proportionately lower incomes and higher stress as a result. For instance, the percentage of low-birthweight infants born to African American mothers is double that for Cauca- sian American mothers. (A summary of the factors associated with increased risk of low birthweight is shown in Table 3-2; Bergmann, Bergmann, & Dudenhausen, 2008; Butler, ­Wilson & Johnson, 2012; Teoli, Zullig & Hendryx, 2014.) Table 3-2 Factors Associated with Increased Risk of Low Birthweight I. Demographic Risks I. Severe morning sickness A. Age (less than 17; over 34) J. Anemia/abnormal hemoglobin B. Race (minority) K. Severe anemia in a developing baby C. Low socioeconomic status L. Fetal anomalies D. Unmarried M. Incompetent cervix E. Low level of education N. Spontaneous premature rupture of membrane II. Medical Risks Predating Pregnancy IV. Behavioral and Environmental Risks A. Number of previous pregnancies (0 or more than 4) A. Smoking B. Low weight for height B. Poor nutritional status C. Genitourinary anomalies/surgery C. Alcohol and other substance abuse D. Selected diseases such as diabetes, chronic hypertension D. DES exposure and other toxic exposure, including occupational E. Nonimmune status for selected infections such as rubella ­hazards F. Poor obstetric history, including previous low-birthweight infant, E. High altitude ­multiple spontaneous abortions V. Health-Care Risks G. Maternal genetic factors (such as low maternal weight at own birth) A. Absent or inadequate prenatal care III. Medical Risks in Current Pregnancy B. Iatrogenic prematurity A. Multiple pregnancy VI. Evolving Concepts of Risks B. Poor weight gain A. Stress (physical and psychosocial) C. Short interpregnancy interval B. Uterine irritability D. Low blood pressure C. Events triggering uterine contractions E. Hypertension/preeclampsia/toxemia D. Cervical changes detected before onset of labor F. Selected infections such as asymptomatic bacteriuria, rubella, E. Selected infections such as mycoplasma and chlamydia and cytomegalovirus ­trachomatis G. First or second trimester bleeding F. Inadequate plasma volume expansion H. Placental problems such as placenta previa G. Progesterone deficiency (Source: Reprinted with permission from Committee to Study the Prevention of Low Birth Weight, 1985, by the National Academy of Sciences, Courtesy of the National Academies Press, Washington, DC.)  Chapter 3 Birth and the Newborn Infant 119 Postmature Babies: Too Late, Too Large LO 3.5 Identify the risks that postmature babies face. One might imagine that a baby who spends extra time in the womb might have some advantages, given the opportunity to continue growth undisturbed by the outside world. Yet postmature infants—those still unborn two weeks after the mother’s due date—face postmature infants several risks. infants still unborn 2 weeks after For example, the blood supply from the placenta may become insufficient to nour- the mother’s due date ish the still-growing fetus adequately. Consequently, the blood supply to the brain may be decreased, leading to the potential of brain damage. Similarly, labor becomes riskier (for both the child and the mother) as a fetus—who may be equivalent in size to a one- month-old infant—has to make its way through the birth canal (Shea, Wilcox, & Little, 1998; Fok et al., 2006). Difficulties involving postmature infants are more easily prevented than those ­involving preterm babies, since medical practitioners can induce labor artificially if the pregnancy continues too long. Not only can certain drugs bring on labor, but p ­ hysicians also have the option of performing Cesarean deliveries, a form of delivery we consider next. Cesarean Delivery: Intervening in the Process of Birth LO 3.6 Describe the process of cesarean delivery and the reasons for its increase in use. As Elena entered her eighteenth hour of labor, the obstetrician who was monitoring her progress began to look concerned. She told Elena and her husband, Pablo, that the fetal monitor revealed that the fetus’s heart rate had begun to repeatedly fall after each con- traction. After trying some simple remedies, such as repositioning Elena on her side, the obstetrician came to the conclusion that the fetus was in distress. She told them that the baby should be delivered immediately, and to accomplish that, she would have to carry out a Cesarean delivery. Elena became one of the more than one million mothers in the United States who have a Cesarean delivery Cesarean delivery each year. In a Cesarean delivery (sometimes known as a c­ -­section), the a birth in which the baby is baby is surgically removed from the uterus rather than traveling through the birth canal. surgically removed from the Cesarean deliveries occur most frequently when the fetus shows distress of some uterus, rather than traveling sort. For instance, if the fetus appears to be in danger, as indicated by a sudden rise through the birth canal in its heart rate or if blood is seen coming from the mother’s vagina during labor, a fetal monitor ­Cesarean may be performed. In addition, mothers over the age of 40 are more likely a device that measures the baby’s to have ­Cesarean deliveries than younger ones (Tang et al., 2006; Romero, Coulson, & heartbeat during labor ­Galvin, 2012). Cesarean deliveries are also used in some cases of breech position, in which the baby is positioned feet first in the birth canal. Breech position births, which occur in about 1 out of 25 births, place the baby at risk because the umbilical cord is more likely to be compressed, depriving the baby of oxygen. Cesarean deliveries are also more likely in ­transverse position births, in which the baby lies crosswise in the uterus, or when the baby’s head is so large it has trouble moving through the birth canal. The routine use of a fetal monitor, a device that measures the baby’s heartbeat during labor, has contributed to a soaring rate of Cesarean deliveries. Nearly a third of all children in the United States are born in this way, up some 500 percent from the early 1970s, when the rate stood at 5 percent (Hamilton, The use of fetal monitoring has contributed to a sharp increase of Cesarean Martin, & Ventura, 2011). deliveries in spite of evidence showing few benefits from the procedure. 120 PART 1 Beginnings Figure 3-4 Cesarean Deliveries The rate at which Cesarean deliveries are performed varies substantially from one country to another. Why do you think the United States has a high rate? Brazil Iran Dominic Republic Italy Mexico Republic of Korea Cuba Argentina United States Spain South Africa Nicaragua France Bolivia Russian Federation Thailand Japan 0 10 20 30 40 50 Cesarean Section Rate (percent) Are Cesareans an effective medical ­intervention? Other countries have substantially lower rates of Cesarean deliveries (see Figure 3-4), and there is no association between successful birth consequences and the rate of Cesarean deliveries. In addition, Cesarean deliveries carry dangers. Cesarean delivery represents major surgery, and the mother’s recovery can be relatively lengthy, particularly when compared to a normal delivery. In addition, the risk of maternal infection is higher with Cesarean deliveries (Miesnik & Reale, 2007; Hutcheon et al., 2013; Ryding et al., 2015). Finally, a Cesarean delivery presents some risks for the baby. Because Cesarean ba- bies are spared the stresses of passing through the birth canal, their relatively easy pas- sage into the world may deter the normal release of certain stress-related hormones, such as catecholamines, into the newborn’s bloodstream. These hormones help prepare the neonate to deal with the stress of the world outside the womb, and their absence may be detrimental to the newborn child. In fact, research indicates that babies born by ­Cesarean delivery who have not experienced labor are more likely to experience breathing prob- lems upon birth than those who experience at least some labor prior to being born via a Cesarean delivery. Mothers who deliver by Cesarean are often less satisfied with the birth experience, but their dissatisfaction does not i­nfluence the quality of mother–child interactions (Porter et al., 2007; MacDorman et al., 2008; Xie et al., 2015). Because the increase in Cesarean deliveries is, as we have said, connected to the use of fetal monitors, medical authorities now currently recommend that they not be used routinely. There is evidence that outcomes are no better for newborns who have been monitored than for those who have not been monitored. In addition, monitors tend to in- dicate fetal distress when there is none—false alarms—with disquieting regularity. Moni- tors do, however, play a critical role in high-risk pregnancies and in cases of preterm and postmature babies (Albers & Krulewitch, 1993; Freeman, 2007). Studies examining what appear, in retrospect, to be unnecessary cesareans have found racial and socioeconomic differences. Specifically, black mothers are more likely to have a potentially unnecessary cesarean delivery than white mothers are. In ­addition, Medicare patients—who tend to be relatively poor—are more likely to have unnecessary cesarean deliveries than non-Medicare patients (Kabir et al., 2005).  Chapter 3 Birth and the Newborn Infant 121 Stillbirth and Infant Mortality: The Tragedy of Premature Death LO 3.7 Describe rates of infant mortality and what factors affect these statistics. The joy that accompanies the birth of a child is completely reversed when a newborn dies. The relative rarity of their occurrence makes infant deaths even harder for ­parents to bear. Sometimes a child does not even live beyond its passage through the birth canal. Stillbirth, the delivery of a child who is not alive, occurs in fewer than 1 delivery out of stillbirth 100. Sometimes the death is detected before labor begins. In this case, labor is typically the delivery of a child who is not induced, or physicians may carry out a Cesarean delivery in order to remove the body alive, occurring in 1 delivery in from the mother as soon as possible. In other cases of stillbirth, the baby dies during its 115 in the United States travels through the birth canal. The overall rate of infant mortality (defined as death within the first year of life) is infant mortality 6.17 deaths per 1,000 live births. Infant mortality generally has been declining since the death within the first year of life 1960s, and declined 12 percent from 2005 to 2011 (MacDorman et al., 2005; ­McDormatt, Hoyert, & Matthews, 2013; Loggins & Andrade, 2014). Whether the death is a stillbirth or occurs after the child is born, the loss of a baby is tragic, and the impact on parents is enormous. The loss and grief parents feel, and their passage through it, is similar to that experienced when an older loved one dies (dis- cussed in Chapter 19). The juxtaposition of the first dawning of life and an ­unnaturally early death may make the death particularly difficult to accept and handle. Depression is common, and it is often intensified owing to a lack of support. Some parents even experi- ence post-traumatic stress disorder (Badenhorst et al., 2006; ­Cacciatore & Bushfield, 2007; Turton, Evans, & Hughes, 2009). There are also differences related to race, socioeconomic, and culture in infant mor- tality, as we discuss in the Developmental Diversity and Your Life section. Developmental Diversity and Your Life Overcoming Racial and Cultural Differences in Infant Mortality Even though there has been a general decline 20 in the infant mortality rate in the United States over the past several decades, African Ameri- 18 can ­babies are more than twice as likely to die 16 before the age of one than white babies. This 13.8 Deaths per 1,000 Live Births difference is largely the result of socioeconomic 14 factors: African American women are significantly more likely to be living in poverty than Caucasian 12 women and to receive less prenatal care. As a re- 10 sult, their babies are more likely to be of low birth- weight—the factor most closely linked to infant 8 6.7 mortality—than infants of mothers of other racial groups (see Figure 3-5; ­Duncan & Brooks-Gunn, 6 5.6 2000; Byrd et al., 2007). 5.5 4 2 Figure 3-5 Race and Infant Mortality Although infant mortality is dropping for both 0 1985 1990 1995 2000 2006 African American and white children, the death rate is still more than twice as high for African American children. These figures show the Non-Hispanic Black All Races Hispanic Non-Hispanic White number of deaths in the first year of life for every 1,000 live births. (Source: Child Health USA, 2009.) 122 PART 1 Beginnings But it is not just members of particular racial groups in In the United States, the U.S. Family and Medical Leave the United States who suffer from poor mortality rates. As Act requires most employers to give new parents up to 12 mentioned earlier, the rate of infant mortality in the United weeks of unpaid leave following the birth (or adoption or States is higher than the rate in many other countries. For foster care placement) of a child. However, because it is example, the mortality rate in the United States is almost unpaid leave, the lack of pay is an enormous barrier for low- double that of Japan. income workers, who rarely are able to take advantage of the Why does the United States fare so poorly in terms of opportunity to stay home with their child. newborn survival? One answer is that the United States has The opportunity to take an extended maternity leave can a higher rate of low-birthweight and preterm deliveries than be important: Mothers who spend more time on maternity many other countries. When U.S. infants are compared leave may have better mental health and higher quality to infants of the same weight who are born in other interactions with their infants (Hyde et al., 1995; Clark et al., countries, the differences in mortality rates disappear 1997; Waldfogel, 2001). (Wilcox et al., 1995; MacDorman et al., 2005; Davis & Better health care is only part of the story. In certain Hofferth, 2012). European countries, in addition to a comprehensive package Another reason for the higher U.S. mortality rate relates to of services involving general practitioner, obstetrician, and economic diversity. The United States has a higher proportion midwife, pregnant women receive many privileges, such as of people living in poverty than many other countries. Because transportation benefits for visits to health-care providers. In people in lower economic categories are less likely to have Norway, pregnant women may be given living expenses for adequate medical care and tend to be less healthy, the up to 10 days so that they can be close to a hospital when relatively high proportion of economically deprived individuals it is time to give birth. And when their babies are born, new in the United States impacts the overall mortality rate (Terry, mothers receive the assistance of trained home helpers for 2000; Bremner & Fogel, 2004; MacDorman et al., 2005). just a small payment (DeVries, 2005). Many countries do a significantly better job than the In the United States, the story is very different. About one United States in providing prenatal care to mothers-to-be. For out of every six pregnant women has insufficient prenatal care. instance, low-cost and even free care, both before and after Some 20 percent of white women and close to 40 percent of delivery, is often available in other countries. Furthermore, paid African American women receive no prenatal care early in their maternity leave is frequently provided to pregnant women, pregnancies. Five percent of white mothers and 11 percent of lasting in some cases as long as 51 weeks (see Table 3-3). African American mothers do not see a health-care provider Table 3-3 Childbirth-Related Leave Policies in the United States and 10 Peer Nations Total Duration Country Type of Leave Provided (in months) Payment Rate United States 12 weeks of family leave 2.8 Unpaid Canada 17 weeks maternity leave 6.2 15 weeks at 55 percent of prior earnings 10 weeks parental leave 55 percent of prior earnings Denmark 28 weeks maternity leave 18.5 60 percent of prior earnings 1 year parental leave 90 percent of unemployment benefit rate Finland 18 weeks maternity leave 36.0 70 percent of prior earnings 26 weeks parental leave 70 percent of prior earnings Child rearing leave until child is 3 Flat rate Norway 52 weeks parental leave 36.0 80 percent of prior earnings 2 years child rearing leave Flat rate Sweden 18 months parental leave 18.0 12 months at 80 percent of prior earnings, 3 months flat rate, 3 months unpaid Austria 16 weeks maternity leave 27.7 100 percent of prior earnings 2 years parental leave 18 months of unemployment benefit rate, 6 months unpaid France 16 weeks maternity leave 36.0 100 percent of prior earnings Parental leave until child is 3 Unpaid for one child; paid at flat rate (income is tested) for two or more Germany 14 weeks maternity leave 39.2 100 percent of prior earnings 3 years parental leave Flat rate (income-tested) for 2 years, unpaid for third year Italy 5 months maternity leave 11.0 80 percent of prior earnings 6 months parental leave 30 percent of prior earnings United Kingdom 18 weeks maternity leave 7.2 90 percent for 6 weeks and flat rate for 12 weeks, if sufficient work history; 13 weeks parental leave otherwise, flat rate (Source: “From Maternity to Parental Leave Policies: Women’s Health, Employment, and Child and Family Well-Being,” by S. B. Kamerman, 2000 (Spring), The Journal of the American Women’s Medical Association, p. 55, Table 1; “Parental Leave Policies: An Essential Ingredient in Early Childhood Education and Care Policies,” by S. B. Kamerman, 2000, Social Policy Report, p. 14, Table 1.0.)  Chapter 3 Birth and the Newborn Infant 123 until the last 3 months of pregnancy; some never see a health- poor women from receiving such care should be reduced. care provider at all (Hueston, Geesey, & Diaz, 2008; Friedman, For instance, programs can be developed that help pay Heneghan, & Rosenthal, 2009; Cogan et al., 2012). for transportation to a health facility or for the care of older Ultimately, the lack of prenatal services results in a higher children while the mother is making a health-care visit. The mortality rate. Yet this situation can be changed if greater cost of these programs is likely to be offset by the savings support is provided. A start would be to ensure that all they make possible—healthy babies cost less than infants economically disadvantaged pregnant women have access with chronic problems as a result of poor nutrition and to free or inexpensive high-quality medical care from the very prenatal care (Cramer et al., 2007; Edgerley et al., 2007; beginning of pregnancy. Furthermore, barriers that prevent Barber & Gertler, 2009; Hanson, 2012). From an educator