Running head: SKIN TO SKIN

Skin to Skin and Breastfeeding Success

Molly Gleason
Methodist College
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Abstract

The purpose of this study is to generate and assess evidence on mother-infant skin to skin

contact on breastfeeding exclusivity and success for use in nursing practice. This study will

explore how one intervention, immediate skin to skin contact after delivery, improves

breastfeeding success rates at hospital discharge. ​Albert​ ​Bandura’s Self-Efficacy Theory (SET)

guides this study. ​A quasi-experimental design will be used that includes 30 participants for the

pilot study. Research instruments include the Infant Breast Feeding Assessment Tool (IBFAT)

and two research questionnaires made for the hospital unit to completed by participants at

hospital admission and discharge. Implications for nursing practice include changing current

practices and forming policies within hospital institutions regarding nursing care during the

“golden hour.” Education must be provided for patients, staff, and providers on this intervention

in order to be successfully carried out after deliveries and to ensure breastfeeding success.
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Introduction

According to the National Center for Chronic Disease Prevention and Health Promotion,

the early postpartum period immediately after birth is a crucial time for establishing

breastfeeding (CDC, 2016). Since the American Academy of Pediatrics recommends that infants

exclusively breastfeed for the first six months of life, this postpartum period should be focused

on mother and infant connection (CDC, 2016). A goal of HealthyPeople 2020 is to “increase the

proportion of infants who are breastfed” (CDC, 2016). On the latest CDC Breastfeeding Report

Card, 81.1% of infants breastfed at least once in their life (CDC, 2016). Only 44.4% of infants

were breastfed exclusively for three months, and 22.3% of infants were breastfed exclusively for

six months (CDC, 2016). In order to meet these goals and improve these rates, breastfeeding

must be supported and well established during the postpartum period. The Academy of Pediatrics

also recommends that direct skin to skin contact be performed immediately after birth until after

the first breastfeeding session is complete (Bramson et al, 2010). The “golden hour” refers to the

first sixty minutes immediately following birth. During this time, the baby transitions from life in

utero to life in the outside world (McCulloch, 2016). Research supports that uninterrupted

contact during this golden hour has a number of health benefits, including mother-baby bonding

and breastfeeding initiation (Sanford Health, 2012). This study will explore how one

intervention, immediate skin to skin contact after delivery, improves these breastfeeding success

rates at hospital discharge.

Statement of the Problem

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The research problem is low breastfeeding rates at hospital discharge per the CDC

Breastfeeding Report Card. Routine hospital care immediately following delivery can separate

the mother and infant during a time where breastfeeding initiation is crucial to immediate and

long term success. The researcher will attempt to answer whether immediate skin to skin contact

after delivery for at least 60 minutes improves exclusive breastfeeding success at hospital

discharge.

Purpose of the Study

The purpose of this study is to determine whether skin to skin improves breastfeeding

success at hospital discharge.

Research Question

In newborns, what is the effect of 60 minutes of immediate mother-infant skin to skin

contact on breastfeeding success rates at hospital discharge when compared with no skin to skin

contact?

Theoretical Framework

Albert​ ​Bandura’s Self-Efficacy Theory (SET) guides the study because mothers must

have self-efficacy when making the choice to perform skin to skin contact and to breastfeed. This

theory states that the individual must have the confidence and belief in one’s self that she can

produce the desired outcome (Bandura, 1977). The patient must believe that she can produce the

desired outcome, which is successful in breastfeeding. This theory suggests that three factors
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influence self-efficacy: behaviors, environment, and personal and cognitive factors. In relation to

the study, behaviors would include the patient’s health behaviors. The environment would

include the hospital in which the patient delivers, the unit which encourages uninterrupted skin to

skin contact following birth and exclusive breastfeeding, and the delivery room that includes care

for the infant to reduce separation. Personal and cognitive factors would include the patient’s

understanding of breastfeeding benefits and the act of performing breastfeeding itself, and if she

has any opinions or biases on breastfeeding, and that the patient understands the effort it will

take and believes she can overcome obstacles to sustain the behavior. SET states that the most

important factor is the cognitive factor, as this produces a change in health behavior. Therefore,

care providers must focus on this factor in order to promote the health behavior of skin to skin

contact and breastfeeding.

Review of the Literature

Study/Author Year Sample/Population Study Design Statistical Tests Intervention Major Findings Limitations

Aghdas et 2014 114 participants Randomized T-test and Skin to Skin to skin One
al. who were control trial, chi square skin participants month
full-term, primary source were used contact or had higher postpartu
healthy mothers for the no skin to rates of m follow
who had a quantitative skin breastfeeding up is a
vaginal birth, data contact. self-efficacy short time
and who analysis. and success at interval
intended to Mann–Whit hospital and longer
breastfeed the ney test discharge and follow ups
infant. was used 28 days are needed
for the postpartum to
parameters when evaluate
with compared to the effects
non-normal the routine of this
distribution care group interventi
s. The (control group on.
IBFAT was of no skin to
found to be skin contact).
a reliable Successful
tool for breastfeeding
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assessing was found in

breastfeedi 56.6% of skin
ng with the to skin
Kapa participants
coefficient versus a
of 0.92 and success rate of
has been only 35.6% in
used in the routine
several care group,
studies. The indicating
home positive
telephone outcomes of
interview skin to skin on
tool used breastfeeding
was found success.
to have
high
internal
consistency
reliability
(cronbach’s
alpha
coefficient
was 0.9).
Bramson 2010 1,842 Prospective Univariate Skin to Mothers who The article
et al. participants cohort quality logistic skin breastfed did not
who had assurance regression contact exclusively structure
delivered a intervention was used with the were more the study
healthy, design, for the mother for likely to be to collect
singleton infant primary source statistical different Hispanic, data on
between 37 and analysis. periods of have high other
40 weeks of time or no school variables
gestation who skin to education, be (the
were not skin a non-smoker, hormone
separated for contact. intend to oxytocin
more than one breastfeed was not
hour during the exclusively, measured
mother’s had a vaginal in this
hospital stay. delivery, used study).
non-central Longer
nervous follow-up
system studies are
analgesia, and needed to
experienced determine
more than one the impact
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hour of skin to of
skin contact extended
during the uninterrup
first three ted early
hours after skin-to-ski
birth. n care on
Exclusive breastfeed
breastfeeding ing
at hospital duration
discharge was after the
found in 7,512 hospital
participants discharge.
who had skin The
to skin contact interval
for more than between
60 minutes early
versus skin-to-ski
exclusive n contact
breastfeeding and the
in only 2,947 final
participants assessmen
who had no t of
skin to skin exclusive
contact. breastfeed
ing was
short.
This was
not a
randomize
d
controlled
trial, as
the
original
data was
collected
as part of
a quality
assurance
program
instituted
by
Perinatal
Services
Network.
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Guala et 2017 252 participants Cohort study, The Skin to Higher rates The need
al. who were over primary source statistical skin of to monitor
37 weeks of analysis contact breastfeeding these
gestation with was with the success in the patients
an infant conducted mother group of skin for an
APGAR score and the versus to skin contact extended
of seven or differences skin to with the period of
greater at five were skin mother when time to
minutes of life. quantified contact compared to determinat
with a with the skin to skin e long
two-sample father with the father term
test for versus no and no skin to results.
proportions, skin to skin contact Only
which skin (control women
calculated contact group) at who
the hospital received
confidence discharge, Baby
intervals. three months, Friendly
and six Hospital
months Initiative
postpartum. compatibl
At hospital e
discharge, informatio
65% of n were
infants who included
had skin to in the
skin contact study.
with the
mother were
exclusively
breastfed
when
compared to
only 36% in
skin to skin
with the
father, and
32% in no
skin to skin
contact. At
three months
postpartum,
55% of
infants who
participated in
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skin to skin
contact with
the mother
were
exclusively
breastfed
when
compared to
only 32% in
skin to skin
with the
father, and
30% in no
skin to skin
contact.
Lastly, at six
months
postpartum,
12% of
infants who
had skin to
skin contact
with the
mother were
exclusively
breastfed
when
compared to
only 9% in
skin to skin
with the
father, and 3%
in no skin to
skin contact .

Methodology

Design Study: ​The design is quasi-experimental comparing 60 minutes of immediate

skin to skin contact after delivery with no skin to skin contact immediately after delivery. This

design study was chosen due to the ability to manipulate the independent variable. Disadvantages
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of this study include a lack of randomization (Polit & Beck, 2014). This design ​separates

participants into two groups: the experimental group (mother-infant skin to skin contact) and a

control group (no skin to skin contact). Participants will be placed in the group of their choice.

This will compare the specific intervention of immediate skin to skin contact to no skin to skin

contact, whether this is taking the infant to the radiant warmer, swaddling, or held by other

individuals. This design was chosen for mothers’ autonomy, so they can choose which group

they will belong to.

Study: ​Participants will include healthy, full-term, mothers who have a vaginal birth.

Inclusion criteria includes a mother’s goal of exclusive breastfeeding until at least hospital

discharge. Cesarean sections will be excluded from the study due to the delay in skin to skin

contact after delivery. Preterm infants will be excluded from the study due to possible feeding

and blood sugar issues related to their development which place them at high risk for

supplementation. Exclusion criteria would include mothers whose pre-delivery intention is to

feed formula while in the hospital. Feasibility issues to consider include the time it would take to

implement the study, cooperation of the participants, availability of a facility, researcher

experience, and ethical considerations. The timeframe for collecting data will begin in May,

2018 and end in August, 2018. The facility will be UnityPoint Health Methodist in Peoria, Il.

Researchers would meet with the unit educator and unit lactation consultants prior to

implementing the study. Hospital staff would be given an in-service on the purpose and design of

the study, the informed consent form, the two questionnaires and the IBFAT, as well as how to

properly perform skin to skin contact and breastfeeding education.

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Instrumentation:​ Research instruments include the Infant Breast Feeding Assessment

Tool (IBFAT) and a research questionnaire (pre-test) before delivery, and a research

questionnaire (post-test) after delivery made for the hospital unit (see Appendix A).

Data Collection/Analysis

The study will take place at UnityPoint Health Methodist Peoria, Il. The sample size will

include participants who are full-term, healthy mothers who have a vaginal birth. The sample

will include experimental participants and control participants for a total of 25 participants in the

study. The independent research variable will be 60 minutes of skin to skin between the mother

and the infant immediately following birth. Variables to consider include maternal age, patient

education level, spouse education level, length of time of stages one and two of labor, infant sex,

infant birth weight, gestational age at delivery, separation of the mother and infant in the first 60

minutes after birth, and placing the infant under the radiant warmer. The dependent variable will

be the rate of exclusive breastfeeding at hospital discharge. The data will be collected by an

initial research questionnaire (pre-test) at the hospital upon admission, an Infant Breast Feeding

Assessment Tool (IBFAT) at the hospital after the first breastfeeding session (see Appendix B),

and a research questionnaire (post-test) at hospital discharge.

Reliability and Validity

The IBFAT has been found to be a reliable tool for assessing breastfeeding with a Kapa

coefficient of 0.92 and has been used in several studies (Aghdas, 2014). The IBFAT assigns a

score of 0, 1, 2, or 3 to four different factors, calculating a score between 0 to 12. The four
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factors include initiating a feeding, rooting, length of time from latch to suck, and sucking

pattern (Altuntas Nilgun, 2014). The research questionnaires made for the hospital unit will be

tested for reliability.

Ethical Issues

The protection of both the mother and the infant are of the utmost importance in this

study. The purpose of the study, to advance understanding of the benefits of skin to skin contact

on breastfeeding success, can aid in developing quality evidence for use in nursing practice.

However, the care provided must take into account and protect the rights of the mother and the

infant. Skin to skin contact will not be withheld for the purpose of the study, and will only not be

performed due to maternal or infant complications or parental refusal. Beneficence would

include physical and psychological harm during the study. One high risk of skin to skin contact

includes infant suffocation in the prone position against the mother’s chest (Jones, 2016). This

occurs when skin to skin is not performed correctly, with high risk infants (as in prematurity or

present illness), or with maternal risk factors (such as sedating medications). These situations

will be monitored carefully and extensive education would take place for the staff on how to

safely and effectively implement skin to skin contact. The study will ensure minimal risk to the

mother and infant. Psychological harm could occur if a mother was either forced to perform skin

to skin for the purpose of the study or if skin to skin was withheld against her wishes. Informed

consent will be obtained from the mother for herself and for her infant, and the mother will be

thoroughly educated and sign a consent based on which group she has chosen (experimental or

control). Participants will voluntarily join the study without coercion and would receive full
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disclosure on the purpose of the study, the participant’s rights and confidentiality, and the risks

and benefits of the intervention. The data collected will be entered on an encrypted device with

names kept fully confidential. The data will then be loaded onto a flashdrive and be kept locked

and secure for 3 years post-study. All ethical considerations of the study will be reviewed by the

Institutional Review Board.

Pregnant participants and neonates are considered vulnerable populations under the Code

of Federal Regulations Title 45 Part 46. Conditions that are required to be met involving the

neonate include the assessment of potential risks to the neonate and that the mother providing

consent be fully informed regarding the reasonably foreseeable impact of the research on the

neonate. The mother will no longer be considered a vulnerable population as soon as delivery

occurs.

Conclusion

The reviewed research indicates that skin to skin contact improves breastfeeding success,

and this must be implemented into nursing practice. After implementation of this study to closer

examine the effects of skin to skin contact on breastfeeding success, policies and procedures

must be created within institutions to promote skin to skin contact after delivery. This

meaningful evidence must be implemented into practice and policies within all hospital

institutions. Education must be provided for patients, staff, and providers on this intervention in

order to be successfully carried out after deliveries. Hospital practices regarding skin to skin after

delivery have an important influence on immediate and long term breastfeeding success.

Physicians, nurses, and hospital staff must change their routine practices in order to eliminate
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maternal newborn separation and barriers to skin to skin contact during this time. Immediate skin

to skin following delivery should be the gold standard of care for all mothers and infants.
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Appendix A
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Appendix B
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References

Aghdas, K., Talat, K., & Sepideh, B. (2014). Effect of immediate and continuous mother–infant
skin-to-skin contact on breastfeeding self-efficacy of primiparous women: A
randomised control trial. ​Women & Birth,​ ​27(​ 1), 37-40.
doi:10.1016/j.wombi.2013.09.004

Altuntas Nilgun, Turkyilmaz Canan, Yildiz Havva, Kulali Ferit, Hirfanoglu Ibrahim, Onal Esra,

Ergenekon Ebru, Koç Esin, and Atalay Yıldız. Breastfeeding Medicine. May 2014, 9(4):
191-195. https://doi.org/10.1089/bfm.2014.0018

Bandura, A. Self-efficacy: Toward a unifying theory of behavior change. Psychological Review,

1977, 84, 191-215

Bramson, L., Lee, J., Moore, E., Montgomery, S., Neish, C., Bahjri, K., & Melcher, C. (2010).
Effect of early skin-to-skin mother--infant contact during the first 3 hours following birth
on exclusive breastfeeding during the maternity hospital stay. ​Journal Of Human
Lactation​, ​26​(2), 130-137. doi:10.1177/0890334409355779

CDC. (2016, December). Breastfeeding report card. Retrieved from

https://www.cdc.gov/breastfeeding/pdf/2016breastfeedingreportcard.pdf

Guala, A., Boscardini, L., Visentin, R., Angellotti, P., Grugni, L., Barbaglia, M., & ... Finale, E.
(2017). Skin-to-Skin Contact in Cesarean Birth and Duration of Breastfeeding: A
Cohort Study. ​Scientific World Journal,​ 1-5. doi:10.1155/2017/1940756

Jones, C. (2016, January 5). Recent reports of skin-to-skin benefits fail to mention key infant
safety risks. The Scientific Parent.org. Retrieved from
https://www.thescientificparent.org/recent-reports-of-skin-to-skin-benefits-fail-to-mentio
n-key-infant-safety-risks/

McCulloch, S. (2015, May 10). Seven huge benefits of an undisturbed first hour after birth.
BellyBelly. Retrieved from https://www.bellybelly.com.au/birth/7-benefits- undisturbed-
first-hour- after-birth/

Sanford Health. (2012, January). The golden hour: giving your newborn the best start. Retrieved
from http://www.sanfordhealth.org/stories/the-golden- hour-giving- your-newborn- the-
best-start