(Received January 19; revision accepted for publication March 14, 1970.)
ADDRESS FOR REPRINTS: (M.H.K.) Babies and Children’s Hospital, 2103 Adelbert Road, Cleveland,
Ohio 44106.
PEDIATRICS, Vol. 46, No. 2, August 1970
HUMAN
MATERNAL
BEHAVIOR
AT
THE
FIRST
CONTACT
WITH
HER
YOUNG
Marshall H. Klaus, B.S., M.D., John H. Kennell, B.S., M.D., Nancy Plumb, B.A., and
Steven Zuehike, B.A.
From the Department of Pediatrics, Case Western Reserve University
School of Medicine, Cleveland, Ohio
ABSTRACT. To explore and examine maternal be-havior in human mothers at the first posthatal con-tact with their young, we quantitatively analyzed photographs taken every second during the first 10 minutes of each contact. We recorded and studied this behavior in 12 mothers 1/2 to 13 1/2 hours following delivery, with their normal, full-term in-fants undressed and placed beside them, and in 9 other mothers during their first three tactile con-tacts with their premature infants (weighing 1,150 to 1,870 gm) in incubators. An orderly progression of behavior was observed in mothers of full-term infants: the mothers started with fingertip touch on the infants’ extremities and proceeded in 4 to 8 minutes to massaging, encompassing palm contact on the trunk. In the first 3 minutes fingertip con-tact was 52%, with 28% palm contact. In the last 3
minutes of observation, fingertip contact decreased to 26% and palm contact increased to 62%. An in-tense interest in eye-to-eye contact was observed at the first contact. Mother-to-infant eye-to-eye con-tact appears to be an important exchange during the development of affectional ties. Mothers of nor-mal premature infants permitted to touch them in the first 3 to 5 days of life followed a similar se-quence, but at a much slower rate. Our results re-veal suggestive evidence of species-specific behav-ior in human mothers at the first contact with their full-term infants and suggest that a re-evaluation is required of the present hospital policies which reg-ulate care of the mother and infant. Pediatrics, 46: 187, 1970, NEWBORN INFANTS, PREMATURE INFANTS,
BEHAVIOR-MATERNAL,
MOTHER
AND NEWBORN IN-FANT, MATERNAL-INFANT INTERAcTION.C
HARACTERISTIC and species-specificmaternal behavior, such as nesting,
retrieving, grooming and exploring have
been observed in non-human mammalian
mothers immediately after delivery.1
Dur-ing studies designed to assess the effects of
immediate, prolonged separation of the
hu-man mother from her premature infant
fol-lowing delivery, we observed an unusual
routine. When mothers first touched their
young, they began by poking and picking
at the infants’ extremities with the tips of their fingers. To explore this behavior in the
human mother we made detailed
observa-tions of women during their first postnatal
contacts with their premature or full-term
infants. This report describes these studies
in 9 mothers of premature infants and 12
mothers of normal, full-term infants.
MATERIAL AND METHODS
Table I describes the mothers and infants
studied. All mothers were well at the time
of labor and were delivered vaginally,
ex-cept for one mother of a premature infant
who required a cesarean section due to
pro-lapse of the cord. The social and economic
status of both groups of mothers covered a
wide range. At the time of the study, all
mothers planned to keep their infants. All
infants were free of anomalies at birth. The
full-term infants were well at birth. The
nine premature infants were normal at 3
days of age, except for mild
hyperbiiru-binemia, subsiding mild respiratory distress
syndrome, and short apenic periods. All
premature infants were nursed in
incuba-tors.
The maternal and infant behavior was
re-corded using a time-lapse camera with a
picture taken every second. Every fifth
frame of the first 10 minutes of a 15-minute
film was analyzed in detail, and the
moth-ers’ remarks were recorded on audiotape.
The two groups of mothers were
TABLE I CLINICAL DATA Data Pre-mature lnfant3 Full-term Infanl8
Number 9 i
Iotliers ages (yr)
mean 25 24
range 19-4 fl-39
Unmarried mothers 3 6
Prinsiparous mothers 4 3
Infants meati birth weights (gm) I,660 3,0’29
groups were told they were being
photo-graphed. \Vomen and their full-term infants
were filmed to 133 hours after delivery
(
average, 5.3 hours)
with a camera 8 to 10 ftfrom their beds, either in a recovery room
on the delivery floor or in a room on the
maternity division. The mother’s bed was
flat, the infant was undressed, and the top
of the infant’s head was placed at the level
of the shoulder, approximately 6 to 8 in.
from its mother. Only the first contact was
recorded for the mothers of full-term
in-fants. Mothers of premature infants were
first filmed 1 to 3 days after delivery
(aver-age, 1.2 days), with the camera placed
in-conspicuously outside the glass wall of the
nursery. A nurse demonstrated how to enter
the incubator, staying only to answer
ques-tions. In contrast to the single filming of
mothers of full-term infants, the first three
contacts of mothers with premature infants
were recorded. The second filming occurred
an average of 3.3 days and the third 5.1
days after delivery.
The following activities were recorded
from the film: the movement of the infant,
position of the mother’s fingertips and
palms on the trunk or extremities of the
in-fant, the amount of time she was smiling,
and the amount of time either physically
supporting or encompassing the infant;
and, for mothers of premature infants only,
the proximity of their heads to the
incuba-tor and the amount of time spent with their
hands inside the portholes. Behavior was
considered “encompassing” if the mother
enclosed either the trunk or head of her
in-fant with her entire hand. \VC also
mea-sured the amount of “en face”
(
a positiondefined by Robson,2 in which the mother’s
face is rotated so that her eyes and those of
the infant meet fully in the same vertical
plane of rotation
)
. Figure 1 illustrates the“en face” position in two mothers.
Interobserver reliability coefficients were
calculated for the individual behaviors.
Sixty-four percent of them were greater
than .90, 91% were greater than .80, and
the average of the reliability coefficients
was .89.
RESULTS
An orderly and predictable pattern of
be-havior was observed when each mother of
the full-term infants first saw her infant.
Commencing hesitantly with fingertip
con-tact on the extremities, within 4 to 5
mm-utes she began caressing the trunk with her
palm, simultaneously showing progressively
heightened excitement, which continued
for several minutes. Her activity then often
diminished, sometimes to such a degree
that she fell asleep with the infant at her
side. Figure 2 summarizes changes during
three time periods in fingertip and palm
contact on either the extremities or trunk
with the mothers of full-term infants. When
behavior in the first and third periods-only
3 minutes apart-is compared, the decrease
in fingertip contact from 52 to 26%, the
in-crease in palm contact from 28 to 62%, the
decrease in touching the infant’s extremities
from 38 to 22%, and the increase in touching
the infant’s trunk from 24 to 49% are all
significant (p < .02) using the sign test.
Comparing the same periods, encompassing
significantly increased from 12 to 30%
(p < .05), while smiling decreased from
45to34% (p <.01).
Mothers of premature infants, studied on
their first three contacts (over a period of
from 1 to 17 days), exhibited an attenuated
sequence of the behavior observed in the
mothers of full-term infants during the first
ma-189
ternal palm and fingertip activity recorded
with premature infants during the first
three hospital visits. The progression from
fingertip to palm contact did not occur over
the time span of the first three contacts in
mothers of premature infants. Instead,
fin-gertip contact increased in the second and
third contacts.
Interest in the eyes of the infants in both
groups was measured from the amount of
verbalization on the audiotapes and from
the amount of time the mothers spent on
_:____________
Fic. 1. Mothers in the “en face” position. “En face” is defined as occurring when the mother’s face is rotated such that her eyes and those of the infant
PALM CONTACT INFANT TRUNK FINGERTIP CONTACT #{149}INFANT EXTREMITY
0-3 3-6 6-9
MINUTES
st 2nd 3rd 1st 2nd 3rd
VISIT VISIT
FIC. 2#{149}Paln and fingerti1) contact on the trunk and extremities at the first Pst1atal contact in 12
niothers of full-tern infants.
the
Cli
face” 1)oSitiOll. Au intense interest inwaking the infants in an attempt to see
their eves OIX’Il was verbalized by 7:3’ of
the mothers. Sonic Illothers (\‘en voiced a
relationship l)et\veeIl the condition of the babies aII(l their eyes. For example. “Open your eves. Oh, come on now, O1)Cfl Ui) your
eves.” “If von P0n ‘our eves, I il1 know
you are alive.” Several iiientioned that once
the infants looked at them, they felt much
closer to them. The mothers of full-term
in-fants showed a remarkable increase in the
time sI)ent ill the en face” 1)OsitiOfl in only
4 to 5 minutes. Figure 4 shows the percent-ages of “en face” in the two groups.
No significant differences in behavior
were observed when multiparous and
pri-miparous or married and unmarried moth-ers were compared.
DISCUSSION
Our results reveal strong evidence for
sPecies-sPecific behavior in human mothers
at the time of the first contact with their
full-term infants. Although each full-term
mother’s experiences, plans, and
expecta-tions differed, and the period of time
be-tween delivery and filming varied, the
ob-served sequences and patterns of behavior
were strikingly similar. The rapid
progres-sion from fingertip to palm and
encompass-ing contact within a period of 10 minutes
does not agree with the observations of
Ru-bin,3 who noted palm and close contact to
develop only after several days. In our
study, the nude state of the infant during
the contact Period might have stimulated a
more rapid progression. Differences in
ma-Fic. 4. Ihe )erccntage of “en face” recorded
during the first visit of 12 mothers of full-term
in-fants and the first three visits of 9 mothers of
pre-mature infants. Lu B I-. z 0 I-4 > Lu (n 0 -J 4 I-0 IL 0 I-z Lu 0
Fic. 3. Palm and fingertip contact on the trunk and
extremities at the first three postnatal visits in 9
mothers of premature infants.
Lu
MOTHERS OF FULL TERM INFANTS
MOTHERS OF PREMATURE INFANTS
Lu Lu B I-z 0 20 > Lu U) ‘5 -i 4 I-tO IA. 0 5
_
rnH
-.
I I I Ia. 0-3 3-6 6-9
MINUTES
st 2nd 3rd
VISIT Lu 90 80 70 Lu 60 0 -J 50 . 40 I-Li 30 0
,.-
20 z I0 Lua-PALM CONTACT INFANT TRUNK
ternal anesthesia might also have altered
the affective state of either the mother or
infant-a limp, sleepy unresponsive infant
whose eyes were closed would not provide
the same stimulus as an active, wide-awake
baby.4
The marked increase in “en face” in the
mothers of full-term infants in just 5
mm-utes and their audiotaped responses concur
with Robson’s suggestion that eye-to-eye
contact is one of the innate releasers of
ma-ternal caretaking responses.2 The marked
concentration on the eyes of the neonate is
also of interest when considered in
conjunc-tion with the early functional development
of the human infant’s visual pathways. His
unusual ability to attend and follow,
espe-cially during the first hours of life, matches
his mother’s interest in his eyes.5’6
There are many possible reasons for the
differences between mothers of full-term
and premature infants. The small, fragile
infant, who to his mother may appear so
small that he may not live,7 the late contact
with little or no caretaking, the lack of
ex-perience with an incubator, and the
strangeness of the premature nursery may
all be barriers to the swift and orderly
pro-gression of behavior seen in the mothers of
full-term infants. Though the two groups
cannot be compared, it is tempting to
sug-gest that the behavior of the mother of a
premature infant is arrested at a stage that
is normally quickly passed in the mother of
the full-term infant.
SPECULATIONS
Clear-cut patterns and orders of
behav-ior (cradling, grooming, nursing,
restrain-ing, and retrieving) have been described in
primates (Rhesus monkey) as components
in establishing early affectional ties
be-tween mothers and their newborn infants.
This report has disclosed that a common
pattern appears to occur in the human
mother at the first contact after birth,
al-though, as Bowlby has stated, “What a
mother brings to the situation . . . derives
not only from her native endowment but
from a long history of interpersonal
rela-tions within her family of origin
(
andper-haps also within other families
)
and alsofrom long absorption of the values and
practices of her culture.” What other
com-mon behavioral sequences are present in
women as they establish affectional ties
with their infants? Have these been
ob-scured by child and mother care practices?
A comparison of immediate postnatal
be-havior with that observed in many
nonhu-man species suggests that this period may
be especially sensitive for the development
of close affectional ties in the human
mother as well as the goat and sheep. Does
separation during this period in the human
result in distinctly aberrant behavior when
the mother and infant are reunited?
Be-cause this period of life appears to be so
critical, modern social and hospital
prac-tices which now separate the mother from
her sick or premature infant for prolonged
periods require a very thorough
re-evalua-tion.10
SUMMARY
To explore human maternal behavior at
the first postnatal contact, we photographed
and analyzed the behavior of 12 mothers of
full-term infants and 9 mothers of
prema-ture infants.
1. Human mothers of full-term infants
have an orderly and predictable pattern of
behavior when presented with their nude
infants shortly after birth. Starting with
fin-gertip touch on the infants’ extremities,
they proceeded in 4 to 8 minutes to
massag-ing, encompassing, and palm contact on the
trunk.
2. In mothers of healthy premature
in-fants cared for in incubators, this sequence
was altered.
3. Early mother-to-infant eye-to-eye
contact appears to be a significant
interac-tion during the development of maternal
af-fectional ties.
REFERENCES
1. Rheingold, H. L., ed.: Maternal Behavior in
Mammals. New York: John Wiley and Sons, 1963.
192 MOTHER’S BEHAVIOR
maternal-infant attachment. J. Child. Psy-chol. Psychiat., 8:13, 1967.
3. Rubin, R.: Maternity care in our society. Nurs.
Outlook, 11:519, 1963.
4. Kron, R. E., Stein, M., and Goddard, K. E.:
Newborn sucking behavior affected by
obstetric sedation. PEDIATRICS, 37:1012, 1966.
5. Brazelton, T. B., School, M. L., and Robey,
J. S.: Visual responses in the newborn.
PEDI-ATRICS, 37:284, 1966.
6. Fantz, R.: Pattern vision in newborn infants. Science, 140:296, 1963.
7. Kaplan, D. M., and Mason, E. A.: Maternal reactions to premature birth viewed as an acute emotional disorder. Amer. J. Orthopsy-chiat., 30:539, 1960.
8. Harlow, H., Harlow, M., and Hansen, C.: The maternal affectional system of Rhesus
mon-keys. In Rheingold, H., ed: Maternal
Be-havior of Mammals. New York: John Wiley and Sons, pp. 254-281, 1963.
9. Bowlby, J.: Attachment and Loss, Vol. I. New York: Basic Books, Inc., 1969.
10. Barnett, C., Leiderman, P. H., Grobstein, R., and Klaus, M.: Neonatal Separation:
ma-ternal side of interactional deprivation. PEDI-ATRICS, 45:197, 1970.
Acknowledgment
This work is supported by the Grant Foundation and the Educational Foundation of America. We thank Drs. R. Fantz and J. Fagan, Susan Reeves, and Dr. S. Miranda for advice and criticism. We also wish to express our gratitude to the nurses in the premature nursery, without whose skill and cooperation this study could not have been under-taken.
CORRECTION
In the article by Bruce D. Ackerman, et
al.
in the June issue of PEDIATRICS, 45:918, 1970,the sentence beginning on line 2 of the left hand column of page 923 should be two
sentences, which should read as follows: Case 6 did not show the spastic signs described
by Van Praagh,28 but did show slowing of the respiratory rate and decreased depth of
