We MUST create a sleep supportive environment for new mothers after birth

Tired mother sleeping with her baby

Sleep is so important for healing, for mental health and possibly even for pain perception that it is functionally a healthcare treatment.

New mothers need to heal from childbirth, manage the pain that often results and are at risk for serious mental health disorders like postpartum depression and anxiety. They need sleep.

So why have we allowed hospitals — through the Baby Friendly Hospital Initiative — to create a sleep environment for new mothers that normalizes maternal exhaustion?

Only one culture cruelly expects exhausted new mothers to fully care for their babies from the moment the placenta is delivered. Ours.

And what can we do to create a more sleep supportive environment?

Everyone knows about the benefits of sleep.

“Sleep services all aspects of our body in one way or another: molecular, energy balance, as well as intellectual function, alertness and mood,” says Dr. Merrill Mitler, a sleep expert and neuroscientist at NIH.

And the benefits aren’t limited to the brain:

“Sleep affects almost every tissue in our bodies,” says Dr. Michael Twery, a sleep expert at NIH. “It affects growth and stress hormones, our immune system, appetite, breathing, blood pressure and cardiovascular health.”

Sleep may affect pain perception and it has a profound effect on mental health.

That’s probably why nearly all cultures, ancient and modern, mandate a period of confinement for new mothers.

Those who practice it typically begins immediately after the birth, and it lasts for a culturally variable length: typically for one month or 30 days, up to 40 days, two months or 100 days. This postnatal recuperation can include “traditional health beliefs, taboos, rituals, and proscriptions.” The practice used to be known as “lying-in”, which, as the term suggests, centres around bed rest.

China:

“Sitting the month”: 坐月子 “Zuò yuè zi” in Mandarin or 坐月 “Co5 Jyut2” in Cantonese. The custom, going back to the year 960, is referred to as ‘confinement’ as women are advised to stay indoors for recovery from the trauma of birth and feed the newborn baby.

East Asia:

Other East Asian cultures, such as South Korean and Vietnamese, have their own versions of “sitting the month”, combining prescribed foods with proscribed activities. Similar practices are popular among Japanese women called 産後の肥立ち “Sango no hidachi” and Korean women called 삼칠일 “Samchilil” for at least 21 days. The new mother is given special postnatal foods, such as seaweed soup in Korea. Samchilil is practiced in addition to other traditions encompassed in sanhujori, which is Korea’s version of postnatal care. During this period of time that could extend beyond the 21 days, women followed principles that emphasize activities and foods that keep the body warm, rest and relaxation to maximize the body’s return to its normal state, maintaining cleanliness, eating nutritious foods, and peace of mind and heart.

India:

Most traditional Indians follow the 40-day confinement and recuperation period also known as the jaappa (in Hindi). A special diet to facilitate milk production and increase hemoglobin levels is followed.

Latin America:

The cuarantena (literally, forty days, also meaning quarantine) is practised in parts of Latin America, and amongst immigrant communities in the United States.] It is described as “intergenerational family ritual that facilitated adaptation to parenthood”…

In other words, most cultures believe that we should mother new mothers, and adequate sleep is considered critical for both recovery of the mother and production of breastmilk for the baby.

Only one culture cruelly expects exhausted new mothers to fully care for their babies from the moment the placenta is delivered. Ours.

Our culture has normalized maternal exhaustion, portraying it as necessary for breastfeeding.

According to The Milk Meg, Meg Nagle:

Feeding your baby back to sleep. Not a mistake, the biological norm! Most babies will need a mid-nap breastfeed and frequent feeds during the night. For months or years.

Prof. Amy Brown speaks disparagingly of mothers who need sleep:

“We are told by so-called experts that you should get your baby in a feeding routine and your baby should not wake up at nights,” said Brown. “But that is really incompatible for breastfeeding. If you try and feed them less, you make less milk. You need to feed at night to make enough milk.”

And the Baby Friendly Hospital Initiative, designed to promote breastfeeding, has encouraged closing well baby nurseries where mothers can leave their babies while they sleep. The BFHI promotes mandated rooming in, leaving mothers fully responsible for the care of their babies from the very first hours after birth.

The BFHI has led to a mini epidemic of babies smothering to death in their mothers’ hospital beds and fracturing their skulls by falling from them.

A recent article asks, Has the push for breastfeeding gone too far?

“One of the requirements is that 80% of the babies need to be at least 23 hours of the day with the mom,” said neonatologist Enrique Gomez Pomar.

That is a chilling statistic. How can a new mother be expected to get hours of unbroken sleep if she is solely responsible for the care of a newborn? She can’t and lactation professionals don’t care about the harm that causes.

“The problem with this comes when you have a mother that had a C-section or when you have a mother that was laboring for two days and is exhausted,” he said.

Like the two moms mentioned earlier, and others. Finding them was no trouble, basically just a matter of posting on neighborhood Facebook groups, looking for recent delivery experiences.

Such stories are common, Pomar said, because giving moms a break — taking healthy babies to the nursery — is a “ding” against the Baby-Friendly designation.

“They’re very strict about their numbers,” he said. “Say the mom says that she wants to rest, then you take the baby to the nursery. That baby, that case, actually dings the hospital.”

What kind of healthcare system penalizes a hospital for allowing new mothers to sleep? Our system under the Baby Friendly Hospital Initiative.

But sleep is critical for healing, for mental health and potentially for pain management. If we care about women — as we claim we do — we MUST create a sleep supportive environment for new mothers.

That means reopening well baby nurseries in ALL hospitals.

That means encouraging mothers to use those nurseries if they feel a need for additional sleep.

That means prioritizing the health of women’s entire bodies and minds, not merely their breasts — as if they are nothing more than milk machines.

As cultures around the world both past and present demonstrate: exclusive, extended breastfeeding isn’t merely compatible with mothering new mothers; it is enhanced by it.

There is precisely ZERO evidence that normalizing maternal exhaustion improves anything. That’s why it’s imperative that we support sleep for new mothers!

  • Ayr

    I am so glad the hospital where my son and my my daughter will soon be born takes the mother’s health just a as seriously as the babies. They make a point of making sure the mother, especially those who have c-sections or extended labor, are aware that they can place the baby in the nursery if they feel the need for extra sleep. Although unfortunately they do have some lactation consultants who are hardcore ‘Breast is Best’ and totally anti formula. But I have seen so many friends go through exhaustion caused by the pressure of felling like they have to breast feed. One friend has two sons, both of which were designated failure to thrive because she insisted on breast feeding though she did not produce enough, she would spend a full hour or more trying to feed her sons. Now they both of eating issues and have to go through food therapy to learn how to eat and that food is actually good for them.

  • Aine

    Can I add a cautionary note about many of these practices? The present day equivalent appears to be the “breastfeeding-moon”
    Where the lactation advice for low supply is to sit under your baby for endless hours and do nothing but feed for a few days. I stupidly tried that for about half a day on the sore with a 19-day old baby and a clear case of low milk supply. My outcome? Massive DVTs in my groin and knee, a leg swollen to twice its normal size and almost black in colour. I had no other risk factors for DVT. Nobody told me of the massive risk in those early weeks post partum. The books all only mentioned clots as a risk for a c-section which wasn’t me. Nobody told me the risk of inactivity. It was awful.

    So confinement, for whatever reason be it the recovery of the mother or the cultish pursuit of breastfeeding, like everything else must be in moderation. I wish I knew about the risks of even a few hours immobility. I still suffer health concerns from it years later.

    • Just wanted to comment that this is a really good way to look at “traditional” practices: Figure out why the practice was adopted, then figure out the downsides and how to correct them.

      For instance, prelacteal feeding is a very common traditional approach, but can be deadly if the child is given honey or tea made with contaminated water; we don’t want to adopt the exact practice of feeding the kid things that might kill, but we should take note that mothers are not expected to provide full nutrition for the child for the first few days.

      The practice of “confinement” has exactly the risk you so unhappily discovered, but it absolutely points to the need for the new mother to rest and recover; an enforced, mandatory time of confinement ensured that she would do so. (Also she’s probably considered ritually unclean for awhile in many cultures.) So let’s learn the lessons from “confinement” and help women rest and recover in a safe manner.

  • EMT2014

    I gave birth for the first time in Japan, where a weeklong hospital stay is the norm, and if you deliver at a maternity hospital (exactly what it sounds like: a fully equipped, fully staffed mini-hospital that only does L&D), 10 days is more common. Often women go back to their hometowns to deliver, and stay there for the first 3 months so their families can look after them. It’s called “satogaeri,” “returning to the village.” It’s so common that there are whole procedures and forms for handing off prenatal and L&D care from your regular doctor to your hometown doctor and special sections in your mother & baby medical record book (another thing I wish we had! One book per child, all the data and records and information, from conception to age 6. SO USEFUL).

    Obviously I didn’t have that option. But I still had a lovely rest in the hospital, with a visit from the doctor every morning, food that ranged from decent to very good (maternity hospitals often use their menus as a selling point, but this was a plain old Red Cross joint), plenty of attention from the nurses (the most cheerful of the breed; other than L&D, Japanese nurses tend to be…stern), and best of all: a well-baby nursery to which the little grub went for the first 3 nights! He got a couple teaspoons of formula there whenever he was hungry (he went on to breastfeed for 2 years and likes me just fine now) until my milk came in and he stayed with me (NOT in bed with me; in his little plastic baby bucket cart). I got lots of rest. It was great. I saw a lactation consultant, got 2 mammary massages, did all the tests and vaccines and stuff that American mothers have to haul their teeny babies to themselves, lessons on bathing and baby care, and was allowed visitors at almost any time during the day. I did have to move to a 6-bed ward from the private room on the third day because I didn’t want to pay for the room for the rest of the stay (ask me how cheap it was anyway! OMG universal healthcare!) but it was empty, so I just pulled the curtains around my bed and it might as well have been a private room.

    The nurses were politely horrified when I told them that American mothers are discharged 24 hours after delivery if there are no complications. “But what if something goes wrong? What if it’s your first baby and you have no idea how to take care of it? You don’t get any rest! American women must be so strong!” I chose not to point out that I (and most women in Japan) was expected (forced) to deliver without any anesthetic whatsoever, even when induced as I was, but given the choice I’m not sure I’d take painkillers over a week in the hospital. Luckily my second came fast and easy here in the US, and the nurses even offered to take her for a little while when she wouldn’t settle the second night (I had a tubal ligation so I got to stay a whole extra 24 hours! Wow!), so I didn’t need too much recovery, but I still would have liked another week of lying in!

  • mabelcruet

    I think we expect too much from new mothers (and dads). I hear people say they were just left to get on with it, I hear about older mothers and grannies chortling about it as a rite of passage, or midwives insisting that you HAVE to do X, Y and Z otherwise you’ll ruin your baby for life. You’re basically handed an alien-you can’t communicate with it, you can’t understand it, if you’re a first time mum you’re panicking about everything from ‘is this how you put a nappy on?’, ‘Should I be using nappy cream or powder?’, ‘How warm should the bathwater be?’ really basic simple things, but it doesn’t matter how much you’ve read and how many parent classes you go to, it’s different when the little alien has arrived.

    I’m an intelligent woman, I can read, even operate machinery-but if you handed me a baby, a bottle and a tub of formula I wouldn’t have a clue what to do. Do you need to sterilise the bottles? Do you need to use boiled water or can you use bottled spring water? What types of nipple things are available and how do you decide which one to use? I think I’d probably hand it back and run away and hide-they terrify me!

    It’s like starting a new job. You’ve got the right qualifications, you’ve sailed through the interview, and you’ve done your research, and yet still on your first day you’re all ‘OMG, OMG, I don’t know what I’m doing!! Everyone will think I’m stupid! I’m going to get sacked, or crash the company’s website!! Arrgh, I’m an imposter and they’ll all find out!!’ And yet we expect mothers to drift serenely into motherhood allegedly having all this intuition and secret knowledge about child care all in place and expect them to manage to do it while totally groggy and punch drunk with exhaustion.

  • Caravelle

    I deeply regret how sleep-deprived I let myself become after giving birth. You hear so much about parents being sleep-deprived as if it’s a normal thing that even though I usually put a high value on getting enough sleep (I’m ideally a 9-hour a night woman) and had planned on “sleeping when the baby sleeps” once the baby arrived, when it didn’t work out that way and I was wired enough to feel fine a lot of the time I just accepted that I wouldn’t sleep much. After reading this blog and the Fed is Best site I insisted with the nurses on getting supplementation when my baby seemed hungry after breastfeeding but I didn’t do the same about sleeping. I even turned down one night nurse who’d suggested taking the baby a bit during the night, because she talked about taking it for three hours and I figured it wasn’t enough sleeping time to be worth it.

    As a result I frequently fell asleep out of exhaustion with the baby in bed (when it happened in hospital I’d then panic about it at the nurses and they’d be like “it’s fine no big deal!”), and I also now completely get how shaken baby syndrome happens. Sleep deprivation is a form of torture after all, and there were two times I actually wanted to hurt my baby in retaliation for preventing me from sleeping. After the second time I put a higher priority on getting sleep and the difference was just magical (non-sleep-deprived me finds screaming babies adorable. “How wonderful to be able to observe such primal expressions of emotion!”).

    I’m a bit mad at myself for buying things like my father telling me new mothers need less sleep (I was so wired in the first few days it actually felt true), but I also feel people around me and the hospital staff in particular should have put more accent on the importance of getting sleep. I feel like sleep deprivation in new parents is framed as an inconvenience, one of those things that suck about being a new parent and you should try and get sleep because you don’t want things to suck, but it’s really just about your personal comfort. When I think it’s actually a fairly important health issue, and a parenting one.

  • Lurker

    What would a supportive sleep environment for new moms look like AFTER those first 2-4 days in the hospital? If it’s not cosleeping, and if for some of us it’s decidedly not our babies sleeping alone, on their backs, on a separate sleep surface (because those babies have decided that alone, on their backs, on a separate sleep surface = awake), what are our options? Is it cry it out at 5 or 7 days old? Is hiring paid help to stay awake and hold our kids for 10 hours/night while they sleep the only way out? (Since some babies will only sleep while in contact with another body. Ask me how I know.)

    Certainly, while I have had some help after each of my kids was born, asking someone to come over to be on duty and awake from 10pm-8am is really not something you can ask of even a close friend or relative.

    (And for the record: only one of my kids was like this. Yes, even if he’d been topped up with formula. Yes, my husband was taking equal shifts. But when your shifts are not getting up in the middle of the night but staying up for several hours in the middle of the night, you still start falling asleep while holding the baby in dangerous places. No, I couldn’t “sleep while the baby sleeps” during the day, because he would also only sleep while being held during the day. No, he wouldn’t take a pacifier, at least not without me holding it in his mouth, which meant I was still awake.)

    • Sarah

      You could’ve been talking about my second here, except she was exclusively formula fed. Thankfully she grew out of it fairly quickly. Unfortunately I think there isn’t a good answer to this. I certainly got zero helpful advice from any medical or nursing professional on the matter. It would have been useful to know which was the least unsafe of our bad options.

      When discussing my experiences, I had quite the set to with a contributor on here a while ago, who was insistent that this couldn’t happen, that we were being special snowflakes, that the key was preparation and to have a situation that didn’t involve the combination of a baby who wouldn’t be put down and no adult who was capable of staying awake all night, that there was always some way other than cosleeping. There was substantial obnoxiousness, but none of it managed to cover that she didn’t have an answer either. I don’t think there is one, unfortunately.

      • Lurker

        I used to say that the most unexpected thing about new parenthood was how much of it I spent comparing the relative risks of asphyxiation. Is it worse to fall asleep holding the baby on the couch? Let him sleep in the car seat? On his stomach? In bed with us? What if we take all the pillows and blankets off? (That’s where we eventually landed.)

        I know there was a post recently about how it’s irresponsible to provide guidelines for safe cosleeping, but for some people, it’s like the whole safe sex/safer sex thing they teach in HS sex ed. There was no “safe sleep” with my oldest, and it would have been nice to know which of our options would have been “safER sleep.”

        • Sarah

          Yeah I think the discussion might have been around that post actually. I know I rather disagreed with Dr Amy’s argument on that particular issue, sounds like you would too.

      • PeggySue

        It sure doesn’t sound like there’s any easy answer. Sounds awful.

        • Sarah

          It was, thankfully long over now. But I don’t think it’s unusual.

  • anh

    When my daughter was born she was immediately transferred to a pediatric hospital and I got to touch her ear before she was gone. And I didn’t see her for 4 days. And I got SO much shit for it. I should be begging to be released early after my C-section to be by her side, sleeping on an army cot.

    But my OB (who is the most amazing OB in all of Europe) listened to me when I told her what a horrible healing experience I had after my older daughter’s birth. How I was fainting from lack of sleep. And she said she was ordering me to stay under their care for the full 4 days so I could really heal. So I spent 4 days being taken care of. I was desperate to start pumping but they made me wait a few hours because they knew how much the uterine contractions would hurt. (Milk still came in). They made sure I ate. When I was having trouble sleeping they gave me medicine to make sure I was getting at least some sleep. I saw a physio who helped get me back on my feet after the C-section.

    Granted I delivered in a crazy posh hospital in London and not everyone can experience this. But I will forever and ever and ever be grateful that I had those 4 days to shore up and then be strong enough to go stay with my daughter at the pediatric hospital and learn to take care of her.

    • anh

      also, the nurses at the pediatric hospital were pure angels. They helped with breastfeeding more than LC ever has by both checking my latch, and also taking my baby between feedings at night so I could sleep. They also kept an eye on me, taking my bp a few times when I asked and helping me administer the anti coagulant shots I needed. So really I was taken care for 11 days. and it made so much difference

  • Cartman36

    Dr. Amy, thank you for spreading awareness about this. We are doing new moms a massive disservice by not taking care of them. Babies will bond with their caregivers even if they (gasp) spend time in the nursery and have formula.

  • Marie

    If I had to do it again, I would take 90% of the money I spent on decorating a nursery and buying baby stuff ( I didn’t go crazy, but there is a lot of pressure to spend way more than you need to on mostly useless stuff) and hired help for at least the first month or so. My daughter is only 10, but if she ever has a baby, that’s what I’ll do for her. My own mom grew up in a large immigrant family where she was expected to go spend a few weeks with her older sisters when they had babies and her nieces did the same for her. Somewhere along the way this fell by the wayside and I have to admit that while I’m not the traditional type, it would be great to have a modern version of this.

  • GeorgiaPeach23

    I barely slept at all the two nights I was in the hospital following my ceserean. If it wasn’t the baby every 2 hours, it was the nurses doing their rounds every 4 hours. So when we got home we put the baby in his crib in his own room and that’s where he’s slept to this day. I recovered very swiftly once I was home and “only” waking up at 3am and 6am to pump. I skipped the midnight/1am routine from the beginning. That 9pm-3am sleep block was an absolute lifesaver those first six weeks.

    What saved me from exhaustion: support first thing in the morning and last thing at night, a baby happy to drink from a bottle and a dad happy to provide one at 1am. From a sleep perspective it was a blessing that baby wouldn’t latch for the first 5 weeks. By the time I was nursing him at night, he was sleeping these glorious 5-6 hour stretches and dad would do one wake up and I would do one and everyone would be ok.

    • Cartman36

      When I had my last, the second night I had JUST gotten him to sleep in his bassinet and I lay down and here comes the CNA wanting to unswaddle him to take his temperature. I said h*ll no. I’ll call you when he wakes up.

  • MaineJen

    Can we get a megaphone and shout this from the rooftop of every single baby-friendly hospital please

  • mabelcruet

    Chronic sleep deprivation is well known in the professional arena-airline pilots have strictly enforced rest periods, for example. In the medical field, we are finally accepting that junior doctors with chronic tiredness and sleep deprivation can be dangerous and adversely impact on patient care. And that’s even with other health care professionals like nurses being around who can keep an eye on things and pick up on errors. So how come we accept all the data about the risks of tiredness when it comes to protecting innocent passengers and sick patients, but we don’t accept that vulnerable and entirely helpless babies are at risk from sleep deprived mothers? The data is there and can’t be disputed. In the UK, when the European directive on safe working hours came into force, limiting the number of hours a junior doctor worked and mandating protected breaks, a lot of older doctors were very grumpy, moaning about how doing 100 hour weeks was a rite of passage and people needed to toughen up. But we now accept the safe medical care is delivered best by rested and alert doctors. So why can’t we accept that safe maternal care is best delivered by wakeful and rested mothers?

  • demodocus

    Usually I read “confinement” in our own historical context as the mother not being allowed to do things even if she wants to. It’s an interesting juxtaposition to see it as women being allowed to ignore all her usual duties and responsibilities. It was probably a mix for mothers of newborns, depending on mood of the day and the mother’s own temperment.

    • mabelcruet

      I’ve been re-reading Phillipa Gregory’s historical books recently, all the ones about Henry VIIII and some of Alison Weir about the same era. The royal women were shut in a room for weeks before and after the birth. The windows were shuttered, fresh air was treated like a poison, they weren’t permitted to walk outside and instead stayed in one room with some of the ladies of the court and the royal midwives. I know it’s a fictional account, but it’s interesting-half of it is horrifying, but there’s other parts that make you think ‘hmm, that’s not a bad idea’. They hung thick ropes from the bed frame for the woman to hold onto during contractions, they seemed to allow a woman to walk around the room during labour, for example, and they used birthing chairs. Some of it was pure superstition-they brought a cat into the room because cats purr when they give birth so that encouraged the woman during hers, and the labouring woman had to have her hair unbound because that unbound the birth canal. The woo pushers were around in the 14th and 15th centuries, obviously!