The neuroscience of birth – and the case for Zero Separation

Abstract

Currently, Western maternal and neonatal care are to a large extent based on routine separation of mother and infant. It is argued that there is no scientific rationale for this practice and a body of new knowledge now exists that makes a case for Zero Separation of mother and newborn. For the infant, the promotion of Zero Separation is based on the need for maternal sensory inputs that regulate the physiology of the newborn. There are harmful effects of dysregulation and subsequent epigenetic changes caused by separation. Skin-to-skin contact is the antithesis to such separation; the mother's body is the biologically 'normal' place of care, supporting better outcomes both for normal healthy babies and for the smallest preterm infants. In the mother, there are needed neural processes that ensure enhanced reproductive fitness, including behavioural changes (e.g. bonding and protection) and improved lactation, which are supported by the practice of Zero Separation. Zero Separation of mother and newborn should thus be maintained at all costs within health services.

Full text

Original Research
doi:10.4102/curaonis.v37i2.1440
hp://www.curaonis.org.za
The neuroscience of birth – and the case for Zero
Separaon
Author:
Nils J. Bergman1
Aliaon:
1Department of Human
Biology, University of
Cape Town, South Africa
Correspondence to:
Nils Bergman
Email:
nils@ninobirth.org
Postal address:
8 Francis Road, Pinelands
7405, South Africa
Dates:
Received: 25 July 2014
Accepted: 12 Sept. 2014
Published: 28 Nov. 2014
How to cite this arcle:
Bergman, N.J., 2014, ‘The
neuroscience of birth – and
the case for Zero Separaon’,
Curaonis 37(2), Art. #1440,
4 page. hp://dx.doi.
org/10.4102/curaonis.
v37i2.1440
Copyright:
© 2014. The Authors.
Licensee: AOSIS
OpenJournals. This work
is licensed under the
Creave Commons
Aribuon License.
Currently, Western maternal and neonatal care are to a large extent based on routine
separation of mother and infant. It is argued that there is no scientic rationale for this practice
and a body of new knowledge now exists that makes a case for Zero Separation of mother and
newborn. For the infant, the promotion of Zero Separation is based on the need for maternal
sensory inputs that regulate the physiology of the newborn. There are harmful effects of
dysregulation and subsequent epigenetic changes caused by separation. Skin-to-skin contact
is the antithesis to such separation; the mother’s body is the biologically ‘normal’ place of
care, supporting better outcomes both for normal healthy babies and for the smallest preterm
infants. In the mother, there are needed neural processes that ensure enhanced reproductive
tness, including behavioural changes (e.g. bonding and protection) and improved lactation,
which are supported by the practice of Zero Separation. Zero Separation of mother and
newborn should thus be maintained at all costs within health services.
Introducon
Problem statement
Until recently, the standard belief about the newborn brain was that it was extremely immature
at birth. It was believed that maturation was primarily a genetically guided process and therefore
relatively impervious to inuence by early care at birth and inevitable adverse experiences. It
was believed that mothers had negligible inuence on their newborns’ brains or bodies and
that the important thing was to ensure newborn survival. There was a legacy of high maternal
mortality, so childbirth was regarded as extremely dangerous and required management by
specialists that ensured survival. In the process, success became measured largely by survival
itself, not by quality of survival or any other behavioural or social outcomes. Over the last 100
years, this world view has shaped the way in which health services are designed and operated.
New ideas that might possibly undermine the good results that modern care has achieved are
often met with resistance.
Aims
The above beliefs and ideas about childbirth are not supported by 21st century neuroscience or
by evidence-based medicine. This brief scientic report provides a critical examination of the
current gap between latest evidence and current practice in newborn care.
Trends
Early childhood development and policy makers refer to the ’rst 1000 days’ as the rst two
years of life, as well as the 270 days preceding birth (Panter-Brick & Leckman 2013). The human
newborn is born with a relatively small brain, but science has shown that it is perfectly wired
and competent for early extra-uterine life (Schore 2001a; Winberg 2005). A human will never
be as alert as after a vaginal birth: noradrenalin wakes up the brain and is 10 times higher at
birth than ever again (Lagercrantz & Bistoletti 1977). High levels of noradrenalin activate the
lungs and, more importantly, ensure early bonding with the mother (Ross & Young 2009). The
mother’s smell (Porter 1998), contact and warmth ‘re’ a pathway from the baby’s amygdala to
its frontal lobe (Bartocci et al. 2000), which connects the newborn’s emotional and social brain
circuits (Nelson & Panksepp 1998). Whilst genes have made this possible (Lagercrantz 1996),
the experience of a mother’s constant and uninterrupted physical presence make it happen
(Hofer 1994). It used to be asked whether ‘nature or nurture drove development; more recently
it was believed that it was nature and nurture AND niche’ – with niche being the environment
– that did so. The current view is to regard both nurture and niche as environment; nature’s
gene effects are multiplied in their interaction with this environment (commonly written GxE)
(Caspi et al. 2010).
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The case for Zero Separaon
Is the safest place for a newborn the observation nursery,
separated from its mother? The Cochrane review on early
skin-to-skin contact (SSC) for healthy newborns and their
mothers (Moore et al. 2012) nds strong evidence that SSC
produces improved physiological regulation and increases
breastfeeding rates. Another Cochrane Review on the
Kangaroo Mother Care (KMC) strategy which includes
SSC, breastfeeding and early discharge (World Health
Organization [WHO] 2003), concludes that KMC lowers
mortality (Conde-Agudelo, Belizán & Diaz-Rossello 2011).
Premature babies are, in many hospitals, believed to be
unstable, thus holding and touch is discouraged. Findings
from a randomised controlled trial published 10 years ago
indicate, however, that low-birth-weight newborns stabilised
because they were not separated from their mothers. In
contrast, preterm babies became increasingly unstable
during their rst six hours of life in optimal incubator care
(Bergman, Linley & Fawcus 2004). Why then do private and
public hospital staff still believe that the mother’s body is a
dangerous place for newborns, when research demonstrates
that premature babies become unstable because their
mothers are not holding them, that is to say, because of
maternal-infant separation (Bergman et al. 2004)?
A common view of a newborn is that it lies in its bed, where
it either cries or sleeps; and swaddling is helpful for stopping
its crying. Crying is said to be good, helping to ll the lungs
with air. Modern neuroscience, however, does not support
this view. The science behind reproductive biology is that all
of a mother’s body sensations help control all of the different
parts of the physiology of the baby (Hofer 2005); this is
called regulation. Prolonged maternal regulation results
in healthy physiological set-points (Hofer 2005), mediated
by epigenetic settings that wire midbrain neural circuits
(Meaney & Szyf 2005). Babies cry because of the absence
of the maternal sensory regulators: they are experiencing
dysregulation (Christensson et al. 1995; Hofer 2005). This
shuts off the baby’s growth hormone and switches on
cortisol (Hofer 2005). Cortisol diverts all the calories and
other neurological resources to ensuring survival, so that
homeostasis is re-established, but at the cost of growth. Such
infants do have ‘stable vital signs’, but the energy consumed
to achieve this homeostasis is not measured (McEwen
& Seeman 1999). When the mother provides regulation
through her own body, all of the baby’s energy is available
for development.
In a study of two-day-old healthy babies sleeping
alternatively in cots and in SSC (their own controls), cot
sleeping showed three times higher autonomic nervous
system (ANS) activation compared with SSC (Morgan, Horn
& Bergman 2011). It is now known that more calories are
required with higher ANS activity; this is accompanied by
high cortisol levels. When cortisol is doing the regulating,
less efcient homeostatic set-points are being programmed
in the physiology of the baby. These set-points remain for
life (Hochberg et al. 2011). The most well established effect
of this re-programming is obesity (Stettler et al. 2005), but
hypertension, high cholesterol and diabetes may become
likely health outcomes because of such changes (Coe
& Lubach 2008). Furthermore, the infant connection of
amygdala to frontal lobe is weakened (Schore 2001b) and
the capacity for trust is compromised when the infant’s basic
needs are not met (Ross & Young 2009).
The swaddled and separated baby lies still with its eyes
closed, and is believed to be sleeping. A study on autonomic
activation (Morgan et al. 2011), showed that quiet sleep was
reduced by 86% in separated babies and their sleep cycling
was almost abolished. There were also specic autonomic
patterns in separated babies, which match perfectly those
described as ‘threat responses’ found in abused children
(Perry et al. 1995). The rst sign of perceived threat results
in vigilance, where crying has survival value since the
perceived threat is further away than the mother. When
the perceived threat is closer than the mother, or if the
mother is not responding, a cry response would, however,
increase danger, thus a state of freeze follows (Misslin
2003). This ‘freeze state’ is produced by intense and total
autonomic activation, with profound avoidance activation
on electroencephalogram (Jones, McFall & Diego 2004). Such
babies lie absolutely still, absolutely quiet, with eyes rmly
closed. This is believed to be sleep! It is however a state of
high arousal, also called ‘fear-terror’ (Perry et al. 1995). When
this state is prolonged, cortisol may initiate harmful changes
that can affect the individual across its lifespan.
Whilst survival rates are important, it is the quality of
survival that actually matters. This is specically true for
preterm infants that spend weeks in separation. It has been
shown that there is a poor quality of survival with respect
to their immunity (Baron et al. 2011; Bird et al. 2010), IQ and
scholastic achievement (Jain 2008; Morse et al. 2009). SSC
with Zero Separation is the biological normal (default) and
is the one intervention above any other that can improve
quality of survival.
The impact of Zero Separaon on the mother
Nursing practices also ensure the mother’s safety, but many
procedures and restrictions have no evidence base. Over
recent years, procedures have been tested methodically in
randomised controlled trials and have been shown to be
unhelpful or even harmful. Examples of such procedures
include shaving, episiotomy, giving birth in lithotomy,
continuous cardiotocograph use and starving during
labour (WHO 2014). Whilst there have been changes,
health professionals still maintain control of the whole
birth experience; the mother is not allowed this basic right
(WHO 2014).
A new mother is often still coerced or encouraged into
thinking that she needs ‘to rest and be alone’ after birth, that
this is good for her and that it is safest and best for her baby
to be in the hospital nursery. Reproductive biology afrms
that there are critical periods that operate in the newborn
(Lee 2003), but equally so in the mother. The stimulations
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Original Research
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hp://www.curaonis.org.za
Page 3 of 4
the newborn provides to the mother, including eye contact,
nipple stimulations and sounds, all work together to trigger
new neural circuits in the mother. One of these is an oxytocin
effect in the anterior cingulate gyrus (Uvnäs-Moberg 2003),
which produces ‘ferocity of defence of young’ (Hahn-
Holbrook et al. 2011; Leng, Meddle & Douglas 2008). The
window for this effect is only a few hours (Uvnäs- Moberg
2003). Early suckling produces prolactin which ensures that
mammogenesis is optimal (Uvnäs-Moberg et al. 1990); the
window for this is two days. Thus, successful breastfeeding
requires Zero Separation. Many other effects are taking
place, but sufce it to say, it is a huge disservice to mothers
when their newborns are removed.
Whilst mothers themselves need observation and care in order
to prevent complications during and after childbirth, this
author believes that current care must accommodate the new
understanding of reproductive biology and developmental
neuroscience. Maternal and fetal outcomes are profoundly
improved when doula care is provided (American College
of Obstetricians and Gynecologists 2014) along with ‘natural
birth’ (Mercer et al. 2007; Smith, Plaat & Fisk 2008), as well as
when the ecologically-valid environment that produces the
‘GxE’ described earlier is ensured. Although the technology
and skills available for newborn and preterm care are
wonderful, they do not require separation; they should instead
be applied to the right place, the mother’s chest (Phillips 2013;
White 2004). In this way, maternal, physiological regulation
will be working in synergy with the baby’s ANS, the need for
technology will be lessened and the intensity thereof can be
reduced, with better outcomes.
The essential requirement is maternal-infant ‘togetherness’,
the rst part of which is SSC, starting from the moment of
birth and Zero Separation (Bergman & Bergman 2013).
Achieving ‘togetherness’ also requires that the father does
SSC (Erlandsson et al. 2007; Gloppestad 1998). Space thus
needs to be provided for both mother and father to care for
their baby. Broader social support is needed, not the ‘one
size ts all’ and ‘no space for father’ that institutional and
impersonal service often codify so rigidly.
Conclusion
The one intervention above any other that would improve
neonatal and maternal outcomes is Zero Separation for the
rst day of every newborn’s life.
Acknowledgements
Compeng interests
The author declares that he has no nancial or personal
relationship(s) that may have inappropriately inuenced
him in writing this article.
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