“Be kind to the mother”: A celebration of the life of Marshall Klaus, 1927‐2017

We wanted to pull together a few personal thoughts about our dear colleague, Marshall Klaus, from a few people who knew him well and were profoundly influenced by his work and life: Michael C. Klein, Penny Simkin, and Diony Young. I met Marshall for the first time as a senior medical student at Stanford in 1965. One night on duty in the neonatal ICU, I became increasingly concerned about the well-being of a 1500 gram premature infant in respiratory distress. His condition was deteriorating. It was becoming more difficult for me to maintain the infant's oxygen level. I had reached the limit of what the respirator and my knowledge could do. Knowing that I needed help, I looked on the list of covering attending physicians. The day's attending physician was Marshall Klaus. I had never heard of Dr. Klaus, who had come to Stanford while I was on a year and a half International Child Health Fellowship in Ethiopia. About three in the morning I called Dr. Klaus. He shambled in. Marshall always shambled, in part because of his residual polio, a right-sided weakness acquired during a polio epidemic when caring for children with the disease. I speculate now that Marshall's exquisite empathy for mothers, babies, and many others might have been as a result of his own experience of disability. He would be shocked to hear me describe him as disabled. He never acknowledged his significant limitation. He just pushed through it. As in Figure 1, showing his weak right side, missing a hike with Phyllis (his wife) was not possible. Marshall listened respectfully to my concerns. He examined the preemie and studied the blood gas results. Expecting some help, I was stunned to hear him say: “What do you think this baby is thinking?” Marshall then said: “How do you think this baby's mother felt when she had to go home and leave her baby behind?” I was confused. I had hoped for some help, but I remember vividly what he next said. With great sensitivity, he said: “Sadly, this baby is going to die and there is nothing further that we can do for him. Let's think about what we can do to help his unfortunate mother.” This was the wrong time for me to hear this. I was still in cure mode, likely based on my age and the Ethiopian experience. Dr. Klaus was looking at the big picture. While developmentally I was not on the same page as Dr. Klaus, it was not too many years later that I was consulting him regularly as a mentor and had come to deeply appreciate his great contributions to the field of maternal-newborn well-being. That night, I didn't know that he was deeply involved with Dr. John Kennell in early attachment research and about to publish in Pediatrics one of the first studies on maternal-infant bonding.1 At that time, he was also germinating the work that was soon to lead to a seminal article in the New England Journal of Medicine: Maternal Attachment—Importance of the First Post-Partum Days.2 His focus was always on how to help the mother connect with her baby. “Be kind to the mother” was his oft heard mantra. Marshall's genius was to reinvent himself on a regular basis. He originally was a pediatrician, a pediatric respirologist, and a newborn specialist. His early much used publications from the 60s were on the newborn lung and newborn respiratory problems. While Marshall was a pioneer in newborn care, the discipline of neonatology had not even been formally invented as a subspecialty of pediatrics until 1975, when he was in the first group to sit for the examination. Soon Marshall and John were writing and researching about what they called “a supportive labor companion.” In 1972 they published in the New England Journal of Medicine a randomized controlled trial of emotional support for what was later to be called a doula study.3 The doula research spanned continents, from Latin America to inner-city USA. It was clear that a doula could change the entire environment of birth—leading to fewer procedures and perhaps some prevention of what we now call posttraumatic stress disorder, which can lead to attachment and newborn caring problems. Translating research into practice is something for which researchers yearn. While Marshall published only a relatively few publications in prestigious journals, they were all hugely influential. His research profoundly changed hospital practice. Prior to Marshall's work, newborns were routinely whisked away to a large, central nursery, with little contact with their mothers in the first few days after birth. Marshall's research profoundly changed our thinking about how to care for newborns. Although there was considerable resistance among hospitals and clinicians, concepts of early skin-to-skin contact, rooming in, and early breastfeeding are now routine; in fact they are now measures of best practices in Baby-Friendly Hospitals.4 Marshall's study of doulas led naturally to his work with Penny Simkin, Annie Kennedy, John Kennell, and Phyllis Klaus, the four together founding Doulas of North America (later DONA) in 1992 and the doula movement itself–leading to a monumental impact around the world. When I recall my interactions with Marshall Klaus over the years, I feel I learned more from him than from any other person in the field. When he would describe the work that he and John Kennell did with parents and babies, during the 1970s to 1990s, I was moved beyond words not only by his message, but also by the warmth, empathy, and kindness he displayed as he described mother-parent-infant attachment and ways to facilitate it. I'm sure that when hearing Marshall speak about mothers and babies, many women wished he had been their pediatrician! Marshall later wrote (in Mothering the Mother, written with Kennell & Phyllis Klaus)5 that the intuitive bond between mother and child is similar to the relationship between a doula and a laboring woman. The doula temporarily takes on a role with the mother that is similar to a mother calming and reassuring her anxious or stressed baby. This description illustrates the differences between the doula and hospital staff, medical care providers, and the woman's partner or other loved ones. The continuous presence, selflessness, and undivided attention provided by the doula, with an understanding of the birth process and ways to make it more comfortable, help the woman feel safer and more confident. This kind of care results in better outcomes for mothers and babies. As an educator and lecturer, Marshall was especially gifted. He could capture and hold the audience's attention, conveying his own fascination with mothers and babies, and his dedication to improving their care. As one of the founders of DONA International, Marshall rarely missed a meeting until his disabilities made it impossible to travel. He, John, and Phyllis helped us to create a definition of a doula and a Scope of Practice that does not duplicate or conflict with the roles of clinical care providers, or fathers or partners. Their foundational work has ensured that laboring women's psychological needs are met, and that they will receive kind, hands-on support, guidance, and comfort through the perinatal period—all this naturally deriving from Marshall's basic research. I met Marshall Klaus in Cleveland, Ohio, in 1974. I had been invited to visit Dr. Klaus to see the research he and his long-time colleague, Dr. John Kennell were doing. I was working as a medical book editor for the C.V. Mosby Co., which was publishing their seminal work, “Maternal-Infant Bonding.”6 The research published in the New England Journal of Medicine2, 3 was the source for the book's content. I had been assigned as editor for the book, and I had the precious manuscript with me. We worked late into the night tweaking and editing and hopefully improving it. The next morning, I visited Rainbow Babies’ and Children's Hospital to see their research areas and the work they were doing. It was fascinating! “Maternal-Infant Bonding,” opened new doors to the care of mothers and babies. During my tenure as Editor of Birth, Dr. Klaus was a favorite speaker at several Birth conferences, “Innovations in Perinatal Care: Assessing Benefits and Risks,” describing the latest research on attachment and advances in neonatal care. He was a valued member of the Birth editorial board from 1977 to 2015, an incredible 39-year run, and during his tenure, reviewed many articles, and wrote several commentaries, book reviews, and other pieces for the journal. What a legacy Drs. Klaus and Kennell have left through their research! Their work has greatly improved mothers', babies', and families' care around the world. Changing hospital practice was not always easy. Hospitals were slow to appreciate and implement the clear implications of Marshall's work on attachment, but once it caught on, immediate skin-to-skin was the rule, large central nurseries disappeared as rooming-in became the norm, and by extension, single-room maternity care. Nevertheless, Marshall's life work on bonding was sometimes controversial, as some misinterpreted the attachment research as a rigid prescription. Misunderstood, Marshall explained that while immediate attachment was ideal, he had great faith in the resilience of both the mother and the newborn. Marshall's impact came home to me in a strange and funny way in the late 1990s when Marshall, Phyllis Klaus, Sheila Kitzinger, and I were invited to Mexico City by Mexican doulas who were trying to introduce doulas and other important changes to a military hospital, a hospital where the nursery was guarded by a camouflaged soldier carrying a machine gun. We gave talks earlier in the day, after which we were invited to meet with various staff members. Marshall and I were taken to the nursery and labor rooms, where we saw more monitoring equipment than was present in most United States hospitals. The mother labored on a fancy birthing bed in a huge, elegantly tiled room. But after birth, the newborn was immediately transferred to be warehoused in a central nursery. We were presented with the institutional problem of excess jaundice and infection. What did Marshall recommend? Without hesitation, but in his usual gentle way, Marshall opined to the hapless neonatologist in charge: “It's easy, just have the mother labor in this large room and keep her baby with her till discharge, breastfeeding on demand. Don't let others handle the baby. Your jaundice and infection will disappear.” The president of the hospital, who was a military general, adorned with lots of gold stars and gold braid, turned to the stunned neonatologist: “You have four months to get this done, or you will be looking for another job.” Oh, to be a benevolent dictator, what good things we could do! In the early 2000s, Marshall was talking about a range of interventions, many inappropriate for mother and newborn. He was particularly incensed by the overuse of epidurals and their associated synthetic oxytocin infusions. He worried about how synthetic oxytocin use could suppress natural oxytocin, the love hormone, thus interfering with attachment. One of his most appreciated offerings, created with Phyllis Klaus, was the book, Your Amazing Newborn,7 used by countless couples. Marshall taught us about the importance of the sensitive period shortly after birth when the newborn's capabilities for interaction were ready to go. He taught about the importance of infant temperament and how newborn crying was a normal expression of the baby's needs, likely helping to prevent some of what later became known as “shaken baby syndrome.” Marshall's passing leaves a great gap, but he will live on through the massive changes that his work has catalyzed. Today, generations of mothers and fathers will experience a totally different birth experience and connection with their newborns than those who gave birth in the mid-20th century and before—and they will not even know why. But we do.

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