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Most mothers take comfort in knowing they have nine months to prepare for the arrival of their baby. These months are very precious, allowing parents to make room physically and psychologically for the arrival of their newborn. It is during these months that many important processes take place – women move into motherhood, couples become parents in the shift to make room for a ‘third’ and often there is a renegotiation of life as we know it – the entire household shifts to accommodate baby. New and experienced parents are often filled with anxiety around the birthing process and the task of looking after someone who is completely dependent on them for their every need. Mothers are particularly focused on feeding, comforting baby, sleep routines and stimulating their baby for optimum development. During this time mothers are preoccupied with their baby, a healthy mechanism that is wired for both the survival and the psychological wellbeing of baby. Winnicott calls this process “primary maternal preoccupation”, a state of attunement between mother and her infant that holds together the fragile psychological state that an infant is born with. Over time, optimum caregiving allows the baby to integrate into a healthy individual who is able to hold themselves together in the throws of internal and external stimuli. This description of the transition to motherhood only really applies when things go well, uncomplicated pregnancies with uncomplicated deliveries to healthy full-term babies. When there is an impingement in this process, there is activated a whole host of psychological mechanisms to cope, both from mothers and from babies. When an infant arrives prematurely, psychic preparation is temporarily halted, for an immediate protective and survival drive takes precedence.
Premature babies under any circumstances are particularly medically and psychologically fragile and mothers of premature infants are well documented to be more likely to experience post-natal depression than mothers who carry their baby to full-term. Bion describes a model that places great emphasis on the emotional faculty of the mother, and implies that the mother is crucial in bearing the full impact of the baby’s raw, indigestible experience, transforming these elements to make them more bearable for the baby. In normal healthy full-term babies, even the slightest feelings of discomfort, such as hunger or wind, feels like an unbearable annihilation or dread. One can hypothesize about the feelings of a premature-infant, and imagine that these feelings of discomfort might be more extreme as their bodies are not developed enough to cope with the demands of the real world. Thus, mothers of premature infants may be called upon to bear even more frightening feelings on behalf of her baby.
Kangaroo Mother Care allows for mothers and babies to have intimate physical contact, where the mother’s body remains the incubator for her baby until he weighs enough to thrive at home. Although this intervention was developed solely in response high morbidity and mortality among low birth weight infants caused primarily by staffing shortages, overcrowding and insufficient resources in neonatal intensive care units, the psychological impact of the intervention has shown to have an impact on the attachment relationship of this dyad. During the initial phase of the KMC intervention in 1978 in Bogotá, Colombia, there was a significant decline in the number of premature infants abandoned by their mothers. The intervention is now used in many developing countries around the world, and is the gold standard for a baby – lead approach to the treatment of prematurity.
Similarly, Kangaroo Care has been established as an essential component of care for babies born prematurely at Rahima Moosa Hospital. This service allows mothers to stay with their premature babies at the ward until they reach their discharge weight of 1.65kg. At Rahima Moosa Hospital, Kangaroo Care involves babies being strapped to their mother’s bare chest for 24 hours a day, in an environment that recreates components of the womb. The ward is temperature controlled, and babies are fed every three hours around the clock. The ward also has 24 hour nursing care, with regular visits from pediatricians who keep a careful watch on these tiny babies. Without this, these babies would spend time in an incubator, far removed from the contact that is so essential for them. It is an environment in which mothers have little else to do besides being with their babies, uniting them in a state of primary maternal preoccupation. Over time however, it has become clear that mothers admitted to the Kangaroo Care Ward are primarily preoccupied with their baby’s survival. Due to the serious nature of medical complications that go along with prematurity and low birth weight, the KMC ward is acutely focused on weight gain of babies who are admitted. It was this at the backdrop in which the KMC ward was identified for a psychological intervention. A weekly psychotherapy group began with mothers and their babies. The aim of this group is to assist mothers to process their birth experience and to bring the baby’s experience to the fore, in order to acknowledge their psychic agency. A common theme from sessions was the difficulty of mothers to think about their babies experience, a defensive blocking of what it might have felt like for these tiny helpless babies. The very nature of the KMC programme, in its attempts to create a space for mothers to incubate their own babies became a source of distress for mothers. They often felt burdened by the strict guidelines of the ward programme, felt guilty if they put their baby down instead of keeping them on their chest, they could not leave the ward and so felt imprisoned where all sense of self and time was lost. Mothers were directly responsible for the weight gain of their baby, and each baby is weighed everyday. This impacted on the mother’s ability to connect to her feelings of having a new baby and her distress of birthing a premature infant. The infant’s very survival depends on his mother, and in the case of a premature infant this is a massive psychological task. Over time, the group sessions were able to assist mothers to process feelings of annihilation and dead, to bring to light and hold feelings for babies who may not survive. This intervention has become an important component for Kangaroo Care, holding mothers so that they are able to hold their babies physically, but also in mind.
See Salisha talk about family therapy on Calabash