A quasi-experimental study was conducted on 108 mothers and their neonates in the maternity department of Hawler maternity teaching hospital in Erbil, Iraq from February to May, 2017. Hawler maternity teaching hospital is one of the largest and busiest maternity hospital in Erbil. Erbil is a city that lies 80 km (50 miles) east of Mosul, and is the capital of the Kurdistan Region of Iraq in which the dominant language spoken by residents is Kurdish [17].
Of the 130 women who were eligible to participate in this study, twenty-two women were unable to continue SSC for 1 h after birth, therefore they were excluded. Finally, we included results from 108 mothers in this study who were randomized into two groups: an intervention group consisting of 56 mothers; and the control group consisting of 52 mothers.
Mothers in both groups were homogeneous in terms of their age and gravidity. Laboring women and newborns who met the following conditions were included in the study:
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Normal pregnancy
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Full-term (38 to 42 weeks of gestation)
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Anticipated normal vaginal delivery and desire to breastfeed the infant at birth
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Lack of receiving any pharmacological pain relief
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Willing to join the study
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Newborns with an Apgar score > 7
In this study SSC meant holding the newborn baby undressed in a prone position against the mother’s bare chest between breasts while the back of the baby was covered with a blanket. This SSC commenced immediately after giving birth and continued for 1 h.
Study instruments
Four instruments were used to collect data. The first instrument was a questionnaire to gather the required demographic and obstetric data from the mothers, including age, gravidity, number of miscarriages, parity, and history of lactation, along with the demographic data of the infants, including weight and gender. The second instrument was a written form that was used to assess the duration of the third stage of labor, which was measured from time of delivery of the infant to the time of complete delivery of the placenta [18]. The third instrument was a written form to record axillary temperatures of the newborns. The fourth instrument was the LATCH breastfeeding assessment tool. LATCH is a sensitive, reliable and valid tool that evaluates breastfeeding techniques based on observations and descriptions of effective breastfeeding [19, 20]. The letters of the acronym LATCH designate five separate assessment parameters: “L” for how well the infant latches onto the breast, “A” for the amount of audible swallowing, “T” for the mother’s nipple types, “C” for the mother’s level of comfort, and “H” for the amount of support the mother has be given to hold her infant to the breast. Each parameter is scored using a numerical score of 0, 1, or 2 [19]. The LATCH scale was designed to assess the success of breastfeeding in this study since it is a useful tool in mother-infant pairs who might benefit from additional skilled support to initiate breastfeeding in specific subgroups at risk of non-exclusive breastfeeding at discharge [21].
The “L” assessment was scored as “2” if good latching was identified (grasps breast, tongue down, lips flanged and rhythmic sucking); “1” if repeated attempts to hold the nipple in the mouth or to stimulate to suck were identified, and “0” if poor latching (too sleepy or reluctant or no latching achieved) was seen. The “A” assessment was scored as “2” if audible swallowing occurred (spontaneous and intermittent < 24 h old or spontaneous and frequent > 24 h old), “1” if a few swallows occurred with stimulation, and “0” if ineffective swallowing occurred. The “T” assessment was scored as “2” if an everted nipple was present (after stimulation), “1” if the nipple was flat, and ‘0’ if the nipple was inverted. The ‘C’ assessment was scored as “2” if the breast was soft and tender, “1” if the breast was filled or reddened / featured small blisters / bruised nipples, and “0” if the breast was engorged or if a crack appeared. The ‘H’ assessment was scored as “2” if good positioning was achieved (no assistance from the staff or mother able to position / hold infant), “1” if minimal assistance was required (i.e., elevate the head of the bed or place pillows for support), and “0” if full assistance was required (staff held the infant at the mother’s breast) [19]. The total score ranges from 0 to 10, with the higher score representing efficient breastfeeding techniques. A total score of more than 7 is regarded as successful breastfeeding, and a score of less than 7 is considered as unsuccessful breastfeeding [19].
Method of data collection
The midwives who worked regularly in the birthing suite agreed that the researcher could attend and record observations of consenting mothers while they were being provided with care. The midwives were requested to behave as if the researcher was not present and not to make changes to their normal practice. The researcher arrived at the delivery room, confirmed the consent of the laboring woman and her relatives, and gained her presence permission from the person managing the birth. The observation equipment included the observation record sheet on a clipboard, a stopwatch, a thermometer and a pen. When birth was imminent, the researcher entered the room to observe. At the moment of birth, the researcher started the stopwatch to record the time following the birth. The researcher stayed with each woman until the end of the first hour after birth.
In the routine care group, the infant was delivered by a midwife, wrapped in blankets, placed under a warmer, and then dried. The Apgar score was determined immediately after the umbilical cord was cut. The infants were provided with this routine care by the midwife working in the delivery room. After the infants were weighed, dressed, and measured, they were handed to their mothers who were encouraged to begin breastfeeding. The routine care of placing a newborn under a warmer is performed in the least time possible (4–5 min) in Hawler maternity teaching hospital due to the presence of only two warmers in the birthing suite for a five-bed room, which are almost always occupied.
With the assistance of the researcher, infants in the intervention group were placed undressed in a prone position against their mothers’ bare chest between breasts immediately after birth and before placental delivery or suturing of tears or episiotomy. The Apgar score was determined, the infant’s nose and mouth were suctioned while on the mother’s chest, the infant was dried, and both mother and infant were covered with a pre-warmed blanket. To prevent heat loss, the infant’s head was covered with a dry cap that was replaced when it became damp. Dressing and measuring of the infant were postponed to one hour after the delivery by a registered midwife.
By standing behind or next to the bed and approaching closer to view the actions, the researcher monitored the infants while they were exhibiting feeding behaviors such as mouthing, licking, latching, and suckling. Breastfeeding initiation time after birth and duration of the first breastfeed were recorded, and then the LATCH scale was used to assess the success of the first breastfeed in the two groups. Some of the mothers in the two groups asked the researcher for assistance to breastfeed their newborns; therefore, the degree of assistance provided by researcher was scored along with other parameters of the LATCH scale (latch, audible swallowing, nipple type, comfort).
Active management of the third stage of labor was performed for all participants by a registered midwife. This composed of three steps: 1) administration of 10 IU synthetic oxytocin, immediately after birth of the baby; 2) controlled cord traction (CCT) to deliver the placenta; and 3) massage of the uterine fundus after the placenta is delivered [18]. The researcher did not interfere with the delivery of the placenta and just observed this procedure being performed by the midwife. Duration of the third stage of labor, which starts with the delivery of the fetus and end with the complete delivery of the placenta was measured by the researcher [18].
In the 1991 World Health Organization (WHO) guidelines it was recommended that rectal temperature should be limited and axillary temperature should be used routinely for the newborn [22]. Therefore, in this study, axillary temperature of the newborns in both groups was checked 30 min after birth. The measuring range of the thermometer was 32–42 °C with accuracy to the nearest tenth of a degree. The thermometer sensor was sterilized with 70% alcohol before each use. After the button power was activated, the digital thermometer was turned on and put with the sensor in the newborn’s armpit, and kept there until the alarm sound was heard. The score on the screen showed the measured body temperature. Based on WHO’s guidelines (1991), an axillary temperature of less than 36.0 °C in newborns is considered as hypothermia [23].
Statistical methods
Data were analyzed using SPSS statistical analysis software. Descriptive relationships between demographic variables and type of care provided for mothers and newborns after birth were explored using means and standard deviations (SD) for continuous variables, whilst categorical variables were described using proportions. The relationship between SSC and time to initiate breastfeeding, duration of third stage of labor, success of breastfeeding, newborn hypothermia, and temperature of the newborn 30 min after birth were analysed using T tests and Chi square tests. Logistic regression modelling was used to examine the effect of SSC and conventional care on outcomes of the study by adjusting for potential confounders like mother’s age, education level, occupation, parity, and newborn gender. The level of statistical significance was set at p < 0.05 in this study. This study had 100% power at a 95% level of confidence to detect 38 and 56% difference in initiation of the breastfeeding and newborn temperature between mother-newborn who experienced SSC and mother-newborns who underwent routine care. The equivalent power value to detect 17% differences in duration of third stage of labor was 81%.
