Current Controversies in Perinatal Care 0095-5108/88 + .

20

john H. Kennell, MD,*

and Marshall H. Klaus, MDt

In perinatology, more than in any other aspect of medicine, widely dif-

fering views about care practices are held, and held firmly, by large numbers
of educated and thoughtful individuals. How can we account for these dif-
fering opinions? To answer this, it may be valuable for us to explore the origins
of some of these controversies, in order to help us make up our minds about
the management of patients and practices today, and to understand contro-
versies in the future. To begin the exploration, it is helpful to reflect upon
the concepts of two scientists who have spent many productive years ana-
lyzing influences on scientific thought and perinatal practices.
In a book entitled The Structure of Scientific Revolutions, Kuhn 9 noted
the following:
Normal science, the activity in which most scientists inevitably spend almost all their
time, is predicated on the assumption that the scientific community knows what the
world is like. Much of the success of the enterprise derives from the community's will-
ingness to defend that assumption, if necessary at considerable cost. Normal science,
for example, often suppresses fundamental novelties because they are necessarily sub-
versive of its basic commitments. Nevertheless, so long as those commitments retain
an element of the arbitrary, the very nature of normal research ensures that novelty
shall not be suppressed for very long.
If perinatal practices are like other scientific fields, Kuhn would predict
optimistically from the long history of science that the advances and proce-
dures that are most valuable clinically will win out in the long run. However,
Jordan, 5 an anthropologist, notes that "any way of doing birth consists of be-
liefs and practices which are mutually dependent and internally consistent.
The work of maintaining this dependency and consistency and thereby the
system's efficient operation, is done through a continuous process of justifi-
cation which draws for its standards on the local definition of birth." On the
basis of her indepth observations, she suggests that the single most powerful
determinant of the structure of a society's birthing system is its concept of
birth. That culture-specific definition of the event is viewed as "a medical
procedure (in the United States), or as a stressful but normal part of family

*Professor of Pediatrics, Deparhnent of Pediatrics, Case Western Reserve University School of

Medicine; Rainbow Babies and Children's Hospital, Cleveland, Ohio
t Director of Academic Affairs, Children's Hospital Medical Center of Northern California, Oakland,
California

Clinics in Perinatology-Vol. 15, No. 4, December 1988 801

802 ]OHN H. KENNELL AND MARSHALL H. KLAUS

life (as in the Yucatan), or as a natural process (as in Holland), or as an intensely

personal-fulfilling achievement (as is the case in Sweden)." She stresses "the
extraordinary extent to which practitioners buy into their own system's moral
and technical superiority," and argues that it will not necessarily be medical
or scientific consideration that will determine the correctness of any medical
intervention. She comments further that the medical professionals in the
United States favor the standard set of obstetric practices, and that this "does
not make them right or wrong in any simple way. Rather it must be understood
as their unselfconscious participation in ... practices which are grounded in
the culture's definition of birth as a medical event. We find ourselves here
in a fuzzy realm where the science of medicine shades into the culture of
doctoring." She adds, "To speak of birth as a biosocial event, then, suggests
and recognizes at the same time the universal function and the culture-specific
social matrix within which human biology is embedded." Jordan would sug-
gest that "any given controversy is decided not on the basis of the kind of
evidence that is produced by the biomedical research (though that evidence
will be put in the service of the enterprise) but rather its status will depend
on how well it fits with the sociopolitical realities and the ideological belief
system of its time and place." Because it is possible that valid scientific evi-
dence for events in this period may be obscured, suppressed, and not fully
evaluated if it is not in tune with our society's system of beliefs, we are not
as optimistic as Kuhn.
The statue shown in Fig. 1 is one example of how strongly most of us are
influenced by a restricted and biased view of the world. This statue, made
in Mexico about 1500 years ago, has been displayed in the Louisiana Museum
located near Copenhagen, Denmark. Only recently has someone questioned
the position of this woman, who appears to be giving birth. Note that if it is

Figure 1. Mexican statue of woman in labor (AD 209-1200) as it was exhibited in

Denmark for 20 years.
THE PERINATAL PARADIGM: Is IT TIME FoRA CHANGE? 803

Figure 2. The statue placed vertically: Is this the position the sculptor had in
mind?

placed as shown in Fig. 2, the seeds on the mother's shoulders will not be
in a position to fall off, her toes will be curled appropriately, and we can
understand how her headpiece can remain undisturbed. For nearly 20 years,
this Mexican statue was placed incorrectly so that the woman labored on her
back, a position not originally intended by the artist, but one that fitted the
commonly held view of the "normal science" of modern obstetrics.
It was only recently that studies of Russell 22 strongly supported the up-
right position and kneeling, squatting, or sitting for birth. Using x-ray ex-
amination of the pelvis, Russell measured the change in the bony outlet when
moving from the supine to the sitting position. The area of the outlet of the
bony pelvis actually increased by an average of 28 per cent in the 96 women
he studied. It is interesting that we continue to use the supine position.
To appreciate our present position within the science of perinatal care,
it is necessary to stand back, observe, and analyze in a manner similar to the
way an anthropologist would view another culture. Such an observer would
note that most of the mothers in our society deliver in hospitals, do not am-
804 JOHN H. KENNELL AND MARSHALL H. KLAUS

bulate during labor, and deliver lying horizontally in the lithotomy position,
and that the father is present for the birth. They would observe that there is
a nurse who comes in and out to examine the mother, and near the end of
labor, the obstetrician spends increasing amounts of time with the mother.
They would detect that, over the past 5 years, there has been an increasing
rate of cesarean section delivery, and that a major reason given for the care
procedures are to decrease perinatal mortality. There is a beginning focus on
attempting to select which mother is carrying an infant who is either growing
poorly or who will die or be damaged if the pregnancy is continued. Thus,
an attempt is made in this society to assess the physical health of the fetus.
The major focus of the society is on caring for infants after birth. Special
technology and skills have been developed to manage the care of exceedingly
small fetuses weighing 500 to 1000 gm; these have evolved, in part, because
of the strong belief in a technology that will, in part, replace the functions of
the uterus. By contrast, surprisingly few research efforts have been directed
at measures to continue the pregnancy.
This report will present two separate care procedures that appear differ-
ent, in many ways, from our own in the United States. The paradigm selected
as the obstetric model was designed by a physician with a different belief
system than our own. As a consequence, he chose another set of scientific
data that he considered important for the development of a different paradigm.
The model for the care of the premature infant uses the same paradigm as we
use in the United States, but applies and extends it differently. The model
of care for the premature infant has altered the practices to make them ap-
propriate for the available technology and resources of the country.
In discussing any controversy, it is necessary to determine whether every-
one has used the same assumptions or paradigm, as described by Kuhn. The
study of a paradigm prepares students for membership in a particular scientific
community where they will later practice. As Kuhn noted, he joins others who
have learned the basis for their practice or medical decisions from the same
model. Those whose research is based on the same shared paradigm are com-
mitted to the same rules and standards for scientific practice.
We are presenting these two differing care procedures to raise the chal-
lenging question of whether we should totally re-evaluate our paradigm of
care for the mother and baby during pregnancy, delivery, and the postpartum
period to determine if we should continue to use the same fundamental tra-
ditions and framework of beliefs as a basis for deciding the correctness or
incorrectness of any research or care procedures.

A DIFFERENT PARADIGM FOR OBSTETRIC CARE

Nearly 20 years ago, Odent17 began to use a new set of standards in de-
termining the appropriateness of obstetric procedures. Odent's paradigm is
based on the assumption that the body of the mother is adapted physiologi-
cally for the delivery of a normal infant, the result of minute evolutionary
changes over thousands of centuries, and that as long as we do not interfere
with the normal processes, the delivery should proceed relatively smoothly.
Odent's training and experience had been as a surgeon, so his view of
childbirth was not restricted by traditional obstetric training and dogma.
Rather, his experience with Berber women delivering in Algeria, and his ob-
servations of the struggles between African women who wanted to squat or
stand during labor and European midwives and physicians who insisted on
THE PERINATAL PARADIGM: Is IT TIME FoR A CHANGE? 805
the horizontal position prepared him to look at obstetric practices with a fresh
and inquiring mind.
The basic components of the Odent paradigm developed gradually over
many years as a result of his questioning of established practices for the care
of women during pregnancy and the perinatal period. He has had an excellent
working relationship with the midwives who have shared in the development
of his paradigm. Most important of all, however, has been his sensitivity and
readiness to learn from the women patients themselves. From this process
came the decision by Odent and the midwives "to let women give birth to
their children, to leave women free to labor as they wished." How is this
achieved, and what are some of the special features of the Odent paradigm?
Before the delivery, the mother visits the unit after coming to Odent for
routine obstetric visits. She becomes acquainted with the midwives in the
unit and develops a warm friendship with them. She is encouraged to come
back as often as she wishes. A whole series of weekly events has been de-
signed to encourage her to come. The objective is to help each mother-to-be
become almost as familiar with the small hospital as her own home, and to
know the midwives well so that she will feel the comfort and familiarity of
a home delivery with close friends even though she will labor and deliver in
a hospital. As one example, every Tuesday evening, there is a period when
the mothers and their families can come to the unit, gather around the piano,
and sing. Singing encourages the pregnant women to feel comfortable and
unself-conscious, and to release a whole range of emotions. Odent, the mid-
wives, the patients, and their families all sing together. The usual separation
between consumer and professional dissolves in the warmth of these gath-
erings. During the singing, the expectant mother has an opportunity to talk
with new mothers, many of whom still come to sing, carrying their babies. It
is not unusual for a mother, her new baby in her arms, to walk from the room
where she delivered a few minutes before and to pause to join the singing
on her way to her room.
Has this general style of prenatal care had an influence on Odent's re-
markable low prematurity rate of 2.5 per cent? (There is interesting data be-
ginning to appear that suggest that increasing the social support during preg-
nancy may reduce labor complications. 14 • 15 • 25 In support of this is the work
of Nuckolls et al., 16 who noted a reduced number of complications during
pregnancy and labor if social support systems were present during periods of
life crisis or stress.) During labor, the mother is in a large room where she
walks with both her husband and a midwife. She is never alone. The same
midwife is present for the entire labor, even though it takes many hours. The
midwives work 48-hour shifts. In the birthing room, every piece of furniture
that compels any one particular position has been removed. There is no de-
livery table. Instead, there is a large, low, square, cushioned platform on
which people can move freely. Every attempt is made to reduce stress. It is
a warm, quiet room with reduced lighting.
Strong support for the Odent approach is found in the work of Diaz et
al. 1 who, in a seven-nation study, demonstrated a significantly shorter length
of labor if the mother walks, and two well-controlled, randomized trials that
have shown a significant decrease in the length oflabor, a decreased cesarean
section rate, as well as the use of significantly less medication if the mother
has continuous social support by a woman during labor. 8 • 24
Odent and the midwives encourage women in labor to give in to the
experience, to lose control, to forget all that they have learned. He does not
endorse Lamaze or breathing exercises. As he writes, "The less a woman has
806 JOHN H. KENNELL AND MARSHALL H. KLAUS

learned about the 'right' way to have a child, the easier it will be for her."
He believes it is important for the woman to allow "her midbrain to lead her
rather than her cortex." Medications are rarely given. The mother is advised
to find positions that are most comfortable for her. Interestingly, at the end
of the first phase of labor, 69 per cent of mothers in this unit get into the
hands-and-knees position, which is known to be ideal for allowing infants in
the posterior presentation to rotate. Although a mother is free to find any
position that gives her comfort and relaxation, most deliveries are in an upright
and squatting position. As previously noted, it is in this position that Russell
demonstrated that the area of the bony pelvic outlet is increased by 28 per
cent. 22 Episiotomies are rarely performed (Paciornik 18• 19 has discovered a
remarkably low incidence of later urinary incontinence and prolapse of the
bladder in Brazilian Indians compared to other Brazilian women. He notes
that the Indians deliver in the squatting position with no episiotomy. It is
also their custom to squat, rather than to sit in chairs.) When necessary, Odent
has facilities for immediate cesarean section. Short periods of monitoring may
be interspersed during the labor if there is any question about the fetal heart
rate. In summary, freedom to labor in any position, continuous support, calm,
intimacy, privacy, and the presence of midwives are emphasized for the first
stage of labor. The bases for his perinatal care include:
1. Reducing stress and providing continuous, empathic social support
2. Allowing the mother's body to determine the best position at any phase
during labor
3. Maintaining the upright position with walking during early labor to
reduce the length of labor
4. Utilizing the upright squatting position to increase the size of the bony
pelvic outlet
5. Recognizing that pregnancy, labor, and birth are normal processes that
proceed best without intervention.
The paradigm of present perinatal practices in the United States has dif-
ferent bases:
1. Considering frequent prenatal visits of mothers during pregnancy to
be essential for identifying abnormal conditions of the mother and
fetus
2. Assuming that the birth of a baby is potentially a dangerous situation
for which preparations, monitoring, and detection during pregnancy
and labor are of major importance
3. Assuming that, because labor is potentially dangerous, all efforts
should be made to detect and manage high-risk deliveries.
It is of interest how many aspects of management encouraged by Odent
are similar to those practiced for 1 to 3 million years by our human hunting
and gathering ancestors and are still continued by the vast majority of non-
industrialized societies. 10 We recently tabulated different birthing practices,
using the Murdock and White Anthropological Sample, 13 in 186 geographi-
cally, linguistically, and historically representative nonindustrialized socie-
ties. This cross-cultural sample resulted from a major anthropologic effort to
facilitate comparative research. To investigate who was present with the
mother during labor, we examined ethnographic material derived from the
Human Relations Area Files, a categorized compilation of primary source
ethnographic data on the world's cultures collected by an interdisciplinary
THE PERINATAL PARADIGM: Is IT TrME FoRA CHANGE? 807
cooperative research organization. 4 These data encompassed 124 societies
from which descriptions of that time period were available. In 122 of the 124
societies, a woman was present with the mother-to-be during labor; in only
two societies, the mother labored alone.
Data were recorded on the position at delivery in 89 of the representative
societies. In 80 per cent of the 89 societies, mothers at delivery were either
in a sitting, standing, squatting, or kneeling position, or they leaned back with
support. In only 20 per cent of societies was the mother on her back or
side.
Interestingly, we also found that 183 societies, or all but three, expected
mothers and babies to nest together for days or weeks after delivery-equiv-
alent to rooming-in-and virtually none permitted the degree of separation
that has been routine in many U.S. hospitals.

A DIFFERENT EMPHASIS FOR NEONATAL CARE*

The Ramon Sarcia Mother and Infant Hospital is a public hospital in Bue-
nos Aires, Argentina where 5000 to 6000 births occur each year. The mothers
come from a very low socioeconomic level. It is the municipal perinatal hos-
pital of the highest complexity in the Republic of Argentina. Eight per cent
of its newborn infants weight less than 2500 gm and 12 per cent of its neonates
are less than 37 weeks' gestation. The hospital has a training program in ob-
stetrics and in neonatology for pediatric residents. In addition, there is a 2-
year postresidency fellowship program in neonatology. Almost all of the neon-
atologists and pediatricians in Argentina, and many from adjoining countries,
train at Sarcia. As a consequence, the excellent quality of neonatal care, and
the philosophy and programs of the Sarcia, such as the residence for mothers,
are copied in part or in full in hospitals in Argentina and nearby countries.
In the Sarda Hospital, a visitor is greeted with the following warning on
the billboards of the Neonatal Department:
RESIDENTS!
It is a rule of this Department to give immediate assistance to the parents of newborns
confined in our Newborn Units. It must be understood that such assistance is in the
nature of a service, including PROMPT INFORMATION to parents, a GUIDED VISIT
(accompanied) of the Unit, an invitation to the Residence for Mothers, etc. Therefore,
any delay in the furnishing of information or assistance to the parents is inconsistent
with the nature of this service.
M. Larugia, M.D. (Departmental Chief)

The nurses and physicians are directed to be sure that the mother receives
and holds her baby immediately after birth at the Sarda to promote optimal
early interaction between the mother and child. (In addition to these inborn
infants, approximately 500 sick newborn infants are referred to the Neonatal
Department from other hospitals.)
There are two neonatal units, one for the intensive care of premature and
sick neonates and the other for the rooming-in of mother and the transitional
care of larger infants with less severe problems, such as hyperbilirubinemia.
In both units, there is a pervasive spirit that is warm, friendly, and inviting

*Note: This section is written in conjunction with A. M. Larquia, Head of the Neonatal Division
and the N eonatology Service, and J. C. Martinez, Chief of Transitional Care and Rooming-in Section,
Hospital Materna Infantil Ramon Sarda, Buenos Aires, Argentina.
808 JOHN H. KENNELL AND MARSHALL H. KLAUS

Figure 3. The mothers' morning meeting in the large room at the Sarda; mothers
holding their infants or sitting next to their incubators.

to parents and families. The intention of the staff has been to create modules
in which the physical care for the infant is linked in an organized manner
with the emotional needs of the new parents. To help parents become attached
to their new infants, the physical facility for the larger infants was modified
by tearing down walls to create a single large room for the infants who re-
quired incubator care or phototherapy. Otherwise, babies would room-in with
mothers from birth on. It was a room in which mothers could visit and care
for their infants at any time and for as long as they would like. The larger
room was chosen so that mothers could talk with other mothers, the nurses,
and physicians whenever they wished. In addition, formal and informal meet-
ings could be held with mothers and fathers, with the mothers either holding
their infants or sitting next to their infants' incubator (Fig. 3). At the entrance,
there is an announcement welcoming all parents. It emphasizes the impor-
tance of parents and their infants to the Sarcia hospital, stresses the willingness
of the staff to help and support them, and, most importantly, it lets them know
that they can rely on the staff, not only as physicians and nurses, but as human
beings.
The corridors and nurseries are decorated with posters of babies with
their parents, accompanied by messages prepared by the Chief Physician at
this Neonatal Unit (Transitional Care and Rooming-in), Dr. Jorge Cesar Mar-
tinez. These messages explain the unit's philosophy, the initial stages of par-
ent-infant attachment, the newborn infant's sensory capacities, and the ways
in which it is possible to communicate with the infant and support emotional
development. Two examples of these messages are:
"Mom, I not only like to sleep and eat, I like to listen to your voice, to be caressed, to
be held in your arms."
THE PERINATAL PARADIGM: Is IT TrME FoR A CHANGE? 809
"Letting a baby cry does not give him the consolation or security that the parents'
warmth and affectionate touches may offer."
Mothers room-in and breast-feed exclusively. There is a hospital team to
promote breast-feeding. There are no bottles, no feeding devices, no dextrose
solutions or formulas. Neonates are not weighed until discharged. The staff
believes that the parents of a newborn infant play major roles and should be
looked after fully. They note that the benefits that rooming-in offers for pro-
motion of mother-child interaction have been emphasized, but very little ac-
tion has been taken on behalf of the parents of sick newborn infants. The
policy at the Sarda encourages and promotes an ever-increasing, active par-
ticipation on the part of parents of premature infants. They have been rein-
stated in their leading role in the care of their infants, and the nurses and
physicians have increased their availability to the entire family group.
Most mothers have had no prenatal check-ups, live far from the hospital,
and lack the financial resources to travel to the hospital. They have poor health
practices and are hesitant about speaking up about their wishes and needs.
In addition, most of these women have little or no support from their family
group. All too often, in the past, this combination of circumstances has led to
pathologic behavior, such as rejection, desertion, maternal indifference, and
ill treatment.
As a consequence of understanding the complex situation faced by the
parents of a premature infant, the staff at the Sarda believe it is the duty of
neonatal units to help place things in proper perspective for the parents. They
suggest that parents must be "activated" and connected to the care system.
The times when parents are not present are times of estrangement. The en-
couragement of breast-feeding and the extraction of colostrum to be given to
the infant like a medication are examples of maternal action connected with
child care in the Sarda paradigm. The parents finally come to accept, know,
and love their child. The established relationship will prevent most patho-
logic behaviors.
The mother has access to the Neonatal Intensive Care Unit with no time
restrictions. She may remain there as long as she wishes. The father may visit
the baby three times a day. The mothers receive medical information daily,
but can talk with doctors or nurses at any time. They are invited to touch and
caress their infants if health permits. There are no contraindications to mother-
child contact when infants are kept in radiant incubators or closed-circuit
incubators with servocontrol. The mother is taught good health practices and
takes part in weekly meetings of parents of premature babies. The mother
starts extracting colostrum at the human milk bank to be given to her infant.
She is instructed in relactation techniques, and her milk production is stim-
ulated with an Egnell pump or similar device, as well as the suckling of other
full-term newborn infants. 7
In summary, the situation faced by mothers of premature and sick infants
at the Sarda and in many units in the United States is overwhelming. Owing
to the social group to which many of the parents belong, there are very limited
possibilities for discussions with relatives and friends. Even if the mother is
well enmeshed in a social group, it is unlikely that she will receive appropriate
understanding and support from individuals who are not familiar with the
problems of premature infants and the prospects of survival with no sequelae.
To improve communication and information-sharing with parents, and to
furnish support and understanding, the staff at the Sarda established a resi-
dence for mothers. This created a community of mothers of premature infants
who face common problems.
810 JoHN H. KENNELL AND MARSHALL H. KLAUS

THE RESIDENCE FOR MOTHERS

Continuing mother-infant interaction during the prolonged period of hos-

pitalization in the Residence for Mothers strengthens their emotional attach-
ment to the child, which may facilitate the child's later development. During
her stay and while she is caring for her infant, the mother learns child-rearing
models that may be different from those of her own culture and family group.
The team of professionals and paramedical personnel in the neonatal unit
is the group to which the mother belongs during her stay, and later, it becomes
her frame of reference. The objectives of the stay in the residence for mothers
are:
1. To strengthen the emotional ties between mother and infant
2. To develop maternal abilities
3. To teach mothers how to look after special children
4. To learn through experience by sharing ideas and by imitation within
the group of resident mothers
5. To strengthen the ties with the hospital
6. To detect and treat difficulties within the family group
7. To help specifically with breast-feeding.
Mothers are invited to stay at the Residence for Mothers when discharged
from the obstetric unit. There are 26 beds and a lounge/dining room to use
as they wish (Fig. 4). The hospital furnishes sheets and meals and provides
cleaning and maintenance services. The mothers are assisted by a group of

Figure 4. One of the dormitory rooms in the Residence for Mothers at the Sarda.
THE PERINATAL PARADIGM: Is IT TrME FoRA CHANGE? 811

volunteers who do not care for the infant, but who assist the mothers so they
may look after the children themselves. Mothers may take up residence either
full-time (i.e., 24 hours a day) or part-time, or they may choose to make daily
visits to their babies.
While they are living in the residence, mothers perform occupational
tasks, set up mutual support clubs, and provide colostrum and mature milk
for the human milk bank. They rest and are well fed, and collectively, they
make up a community with common concerns-their children's premature
birth and/or illness. The mothers living in the residence usually establish a
solid relationship with their infants and the hospital. This is demonstrated by
the excellent rate of breast-feeding; continuous attendance at the outpatient
consulting room for follow-up evaluations; the disappearance of preventable
diseases or problems, such as malnutrition and diarrhea, child abuse, neglect
or desertion of children, and maternal deprivation. The Residence for Mothers
is the hospital's lowest cost division.
Weekly meetings, chaired by one of the team members, are held in the
Residence's lounge with the parents of premature babies. These meetings are
educational for all the parents, but particularly for the fathers and mothers
who have decided not to stay at the hospital. Parents learn about the char-
acteristics of their children, breast-feeding, and care of their babies at home.
There are discussions about the practical problems that may be encountered
in the daily life of children.
Thus, parents have a place to meet with other parents and share their
experiences and doubts. From time to time, nurses attached to the neonatal
unit may attend these meetings to discuss subjects specifically related to child
care.
The staff of many neonatal units in the United States will find they are
providing one or more of the components in the Sarda paradigm. But few have
established a residential program for mothers. The first such unit was reported
at Baragwaneth, South Africa, where all the mothers of premature infants
lived-in and breast-fed their infants. 6
The Sarda program draws upon the extensive research on premature in-
fants and their parents. It applies those features that have been shown to
enhance the attachment of mothers to sick and premature infants and de-
creases or removes factors, such as mother-infant separation, that interfere
with it. Minde et al. 12 found that mothers who visited the nursery frequently
during their infant's hospitalization stimulated their infants more at home.
Those mothers who visited little during their child's hospitalization stimu-
lated much less than other mothers at home. Many other studies 2 • 21 • 23 suggest
similar relationships between early interactions and later development.
Minde and colleagues have also reported a randomized trial in which parents
of premature infants who participated in self-help groups rated themselves
as more competent on infant care measures; visited their infants more often;
and touched, talked to, and looked at them en face more. 11 This interest in
the infant persisted at home until at least 3 months after discharge. Would
this be true of the mothers who lived in the Residence for Mothers?
At the Sarda, the increased opportunity for parents to interact with and
care for the infant would be expected to foster warm maternal feelings and
an increase in self-esteem. With little or no separation, tliere should be less
guilt and less mourning. In such a supportive environment, the incidence of
successful breast-feeding is increased. The repeated interactions associated
with nursing enhance mother-infant attachment.
In this report, we have presented two different approaches to caretak-
812 JOHN H. KENNELL AND MARSHALL H. KLAUS

ing-one within our paradigm, the other outside our frame of reference. We
did this to emphasize that very early in any controversy, we must decide if
we are involved with another paradigm, as this may reveal strange biases and
prejudices. As an example, although Odent's methods are strongly supported
by research studies, his work is not discussed, debated, or even studied in
the United States.
Why has the Odent paradigm not been studied in the United States? Why
have so many of the individual components that have been shown to be ben-
eficial in careful research studies not been studied further in the United States
or applied? Why are these paradigms so different than our systems in the
United States? With the high rate of serious complications in survivors with
low birth weight (<1000 gm), should we not shift our focus to behavior that
lengthens the pregnancy? At the same time, we have almost totally neglected
many social and behavioral interventions that significantly decrease the pre-
maturity rate. 3 • 20 It seems most likely, as Jordan indicates, that they have not
been included because they do not fit our medical system. That is why it is
important for us to look at other paradigms and to consider issues with an
increasingly broad perspective. If we do, we might find, as Kuhn has pre-
dicted, that the advances and procedures that are most valuable clinically
indeed will prevail in the long run.

ACKNOWLEDGMENTS

We wish to thank Betsy Lozoff and Lois Klaus who coded the ethnographic material for all 186
societies. We are grateful for the support, which made the presentation of this information possible,
from the Arthur Vining Davis Foundations, The Pittway Corporation Charitable Foundation, The
Thrasher Research Fund, The William T. Grant Foundation, and grant ROl HD16915 from the
National Institute for Child Health and Human Development.

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2. Field T, Sostek AM, Goldberg S, Shuman H (eds): Infants Born at Risk. New York, Spectrum
Publications, 1979
3. Heins HC, Nance NW, Ferguson JE: Social support in improving perinatal outcome: the re-
source mothers program. Obstet Gynecol 70(2):263, 1987
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Department of Pediatrics
Rainbow Babies and Children's Hospital
2074 Abington Road
Cleveland, Ohio 44106