Kangaroo Mother Care and the Bonding Hypothesis

PEDIATRICS Vol. 102 No. 2 August 1998, p. e17

Réjean Tessier*, Marta Cristo, Stella Velez, Marta Girón, SW; Zita Figueroa de Calume, Juan G. Ruiz-Paláez, Yves Charpak, and Nathalie Charpak

From the *School of Psychology, Laval University, Québec, Canada; ISS-World Lab, Kangaroo Mother Care Program, Clinica del Nino, Santa Fe de Bogotá, Colombia; - Clinical Epidemiology Unit, Faculty of Medicine, Javeriana University, Santa Fe de Bogotá, Colombia; and EVAL (Institut pour l'Évaluation dans le domaine Médical, Médico-social et de Santé Publique), Paris, France.

DISCUSSION

The psychological impact of KMC is obvious, but it also is more complex than we had initially thought. The mothers in the KMC group who carried their infant in the skin-to-skin position felt more competent than did their TC counterparts. The infant’s health status, however, was also a major determinant of the mothers’ attachment behavioral patterns.

The Subjective Bonding Indices

The mothers’ global perception of giving birth to a premature infant was different in the two groups. Mothers in the KMC group felt more competent, but also more isolated than did mothers in the TC control groups. First, the sense of competence was clearly much higher in the KMC group, and especially when the intervention started soon after birth (1 to 2 days). In this subgroup, the infants were basically healthy at birth and had had an early close contact with their mothers. Is there is a skin-to-skin effect? Because we had an a priori control on many variables, we suggest that the difference observed between these two groups may be attributable to close contact between the mother and child. It might be explained by empowerment of the mother’s feelings, making her more responsible and confident in her capacity to care for her infant. In contradiction to Whitelaw and colleagues,⁷ but according to Legault¹⁰ and Affonso and coworkers,²¹ we conclude that skin-to-skin contact at discharge is more effective in terms of the mothers’ feelings than is traditional routine care in hospitals. Moreover, because the difference between the two groups decreases gradually as the delay between birth and start of TC or KMC intervention increased (Table 4), we can corroborate that early timing is more effective than late timing as a means to enhance the mothers’ sense of competence toward her premature infant.

The timing (delay) of contact between a mother and her child after birth has been an important theme in studies aimed at challenging the bonding hypothesis. In Klaus and colleagues’ first study,¹⁴ the mothers in the experimental group had 1 hour of skin-to-skin mother-infant contact (within the first 3 hours), followed by 5 hours’ contact per day for 3 successive days. The authors concluded that the increased contact had enhanced the mothers’ attachment behavioral patterns, but they could not determine whether it was the initial 1-hour contact or the 15 hours of additional contact that produced the effect. Because the idea of a very short parent-infant bonding period has been widely criticized, Klaus and Kennell in 1982²² extended it to several hours or days after birth. However, we still lack the empirical data to determine the optimal length of time required -- in these first few hours or days after birth -- to produce an effect. From the data obtained in this study, we can empirically suggest that close mother-infant contact during the first 2 days after birth is optimal to produce a major change in a mother’s sense of competence toward her infant.

Furthermore, based on our data, we also can extend the latter finding to infants that have a poor to bad health status after birth. We found that in infants who needed intensive care, the mothers had a heightened feeling of competence in the KMC group relative to those in the TC group. This finding was especially true for the subgroup that left the hospital earlier, ie, at between 3 and 14 days (data not shown). This discovery indicates a definite advantage of using skin-to-skin contact as early as possible, suggesting that kangaroo-carrying interventions should be encouraged during the NICU period. We are thus tempted to speculate that skin-to-skin contact is not only beneficial in the first days but also at any time during the perinatal period.

Second, the KMC intervention also produced negative feelings in the mothers. They felt more isolated than did mothers in the TC group. This was especially true for those whose infant spent a longer time in hospital. This may have occurred when the infant could not gain sufficient weight or suckle properly, had an infectious disease, or was sick in any way. These mothers may feel burdened with too many responsibilities in taking care of the infant and, consequently, feel overwhelmed and that they are not getting sufficient help from the hospital staff and family. This suggests that in such cases, we should add a social support to the KMC’s usual components.

However, feelings of stress and worry in the mothers in the KMC group were maintained at a mean level in any Delay condition, which was not the case for the mothers in the TC group whose stress level was delay-dependent. The latter felt less preoccupied than did mothers in the KMC group when the infant left the hospital early, but they felt much more stressed when the infant stayed longer. Our hypothesis is that KMC gives the mother a feeling of control over her stress and worry about the infant’s health, and that this sensation acts in a protective manner, making her more stress-resilient.

We thus confirm the first part of our hypotheses related to the mothers’ perceptions of a premature birth experience. There is a direct intervention effect favoring the KMC mothers’ sense of competence and the TC mothers’ perception of social support, but the moderating effects are more prominent. Mothers in the KMC group had a higher sense competence when the delay was shorter (bonding effect) and when the infants needed intensive care (resilience effect). Feelings of stress for mothers in the KMC group was lower than that for mothers in the TC group when the delay was longer (resilience effect). Finally, mothers in the KMC group felt less supported or more isolated when the delay was longer (isolation effect).

Maternal sensitivity was moderately induced by the KMC intervention in the sense that these mothers were more sensitive and stimulated their infant more cognitively in the context of a longer hospital stay. This may be interpreted as a resilience effect that also was expressed by the mothers’ perceptions of their competence and low stress level in these high-risk situations. However, in the context of the infant needing intensive care, observed maternal sensitivity was not increased directly by skin-to-skin contacts. The infant’s health appeared as a far more important factor, and mothers tended to provide more stimulation to infants who had a poor health status, which, in turn, led to a more responsive infant. Our initial interpretation of this finding was that poor health may increase the mother’s attention, worry, and responsiveness to her infant and that a infant who had been overstimulated and stressed in an NICU -- in some cases for a considerably long time (up to 50 days in this sample) -- might have become oversensitive to any cues, including maternal cues. This interpretation, however, is not confirmed by our data, which showed that the subgroup that spent an average of 17 days in the NICU had a lower responsiveness to their mothers than did infants in the other group who spent an average of 4.4 days in the NICU (data not shown). Therefore, we hypothesize that this marked orientation toward the sick child might be the beginning of a continuing protective behavioral pattern observed frequently in the interaction between a mother and a sick child during the first years of life.²³^,²⁴ This might be interpreted as a natural trend observed in the mothers’ behaviors aimed at protecting sick and feeble infants, and are as such, well adapted to the child’s situation. However, it could be readily construed that mothers who continue to demonstrate oversensitivity to a child would later be overprotective. This conclusion, however, would require validation in a longitudinal study. At present, we can only conclude that the mothers in both groups, but more consistently in the KMC group, showed behavioral patterns that were adapted to a child’s health status. They were more sensitive and more responsive to weak children. This effect overshadowed the KMC carrying effect.

In conclusion, observations of the mothers’ sensitive behavior did not show a definite bonding effect, but rather a resilience effect. This is attributable to the KMC intervention: mothers in the KMC group were more sensitive toward an at-risk infant whose development has been threatened by a longer hospital stay. Otherwise, we observed that mothers in both the KMC group and the TC group had behavioral patterns that were adapted to the child’s at-risk health status and to the precarious condition of some premature infants requiring intensive care. We conclude that the infant’s health status may be a more prominent factor in explaining a mother’s more sensitive behavior, which overshadowed the kangaroo carrying effect in our study.

From a subjective perspective, results are different. We observed a change in the mothers’ perception of her child, which was attributable to the skin-to-skin contact in the kangaroo carrying position. This effect was related to a subjective bonding effect that may be understood readily by the empowering nature of the KMC intervention. Moreover, in particular situations when the infant needs intensive care at birth or has to remain in hospital longer, mothers who carried their infant in the kangaroo position felt more competent than did mothers in the TC control group. This is what we call a resilience effect. There also was an apparent negative effect on the KMC mothers’ feelings: when the infant has to stay in hospital longer because of health problems or gestational immaturity, there appeared to be a gap between the mothers’ stronger needs to be helped and the feeling of received support. We interpret this as an isolation effect. To minimize this deleterious effect, we would suggest adding social support as an integral component of KMC.

These results suggest that KMC should be promoted actively and that mothers should be encouraged to use it as soon as possible during the intensive care period, up to 40 weeks’ gestational age. Thus, KMC should be viewed as a means of humanizing the process of giving birth in a context of prematurity. This finding confirms the conclusions of the 1996 Trieste workshop²⁵ suggesting that KMC should be promoted both in hospitals and after early discharge.

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