The effect of mother and newborn early skin-to-skin contact on initiation of breastfeeding, newborn temperature and duration of third stage of labor

The rate of maternal and neonatal mortality is unacceptably high in Iraq. The maternal and neonatal mortality rates are as high as 84 cases per 100,000 live births and 23 cases per 1000 live births, respectively [1]. These figures are significantly higher in Iraq than developed countries, for example neonatal mortality rates was reported to be 1.74 per 1000 birth in the UK in 2015 [2]. Perinatal infections and fetal hypoxia are the most important causes of neonatal deaths in Iraq, which can be avoided through early initiation of exclusive breastfeeding [1]. However, the prevalence of early initiation of breastfeeding in Iraq is quite low at 38.1% [3].

As recommended by the Baby Friendly Hospital Initiative (BFHI), newborn infants should be placed in skin-to-skin contact with their mothers immediately after their birth for at least one hour, and mothers should be helped to initiate breastfeeding within the first half-hour following the birth of their infants [4, 5]. The term skin-to-skin contact (SSC) is defined as the placement of a naked infant, occasionally with a diaper or a cap on, on its mother’s bare skin, and the exposed side/back of the infant covered by a blanket or a towel [6]. The movement of the infant’s hands over the mother breasts during SSC leads to increased secretion of oxytocin, which results in increased secretion of breast milk [7].

It is also known that SSC after birth promotes newborn temperature regulation, metabolic adaptation, and maintenance of glucose blood levels. Infants have a reduced capacity to generate heat, which leads to a rapid decline in temperature. This is why maintenance of temperature is one of the most important needs of infants at birth [8]. While the mother and her infant are in SSC, heat is transferred from the mother to the infant, during which the mother’s body temperature activates the infant’s sensory nerves, which in turn results in the infant’s relaxation, reduction in the tone of the sympathetic nerves, dilation of skin vessels, and increase in its temperature [7]. Hypothermia during the newborn period is widely regarded as a major contributory cause of significant morbidity and, at its extreme, mortality in developing countries [9]. High prevalence of hypothermia has been reported in countries with the highest rate of neonatal mortality, where hypothermia is increasingly gaining attention and significance as a critical intervention for newborn survival [10].

In addition providing the newborn with numerous benefits, SSC is associated with many benefits for mothers. Secretion of maternal oxytocin in mothers who receive SSC strengthens uterine contractions, which in turn helps the placenta to separate and the duration of the third stage of labor to decrease [11]. The third stage of labor, which involves separation and expulsion of the placenta and membranes, starts immediately after the delivery of the fetus [12]. In most obstetric settings, active management of the third stage of labor is now a common practice to accelerate the third stage, in which synthetic oxytocin that causes the uterus to strongly contract is administered. In a spontaneous, uncomplicated birth, it is reasonable to plan a physiological or natural third stage by utilizing the mother’s own oxytocin [13, 14].

There is an urgent need to reorganize and restructure health services throughout Iraq, and maternity and neonatal care is one of the critical areas that needs substantial efforts in this regard [15]. As a cost-effective, simple and appropriate method, mother and newborn SSC after birth should be practiced in order to improve post-delivery care and potentially save the lives of mothers and newborns [16]. There are very few studies that focus on the effects of SSC on maternal and newborn health in Iraq. The present study was carried out in order to determine the effect of early maternal-newborn SSC after birth on the duration of the third stage of labor, early initiation of breastfeeding, and newborn temperature.

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.

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.

There was an association between mother and newborn SSC and breastfeeding initiation time after birth. Newborns who experienced SSC initiated breastfeeding 2.41 ± 1.38 (M ± SD) minutes after delivery, while newborns in the routine care group started breastfeeding 5.48 ± 5.70 (M ± SD) minutes following their birth (p <  0. 001).

Fifty-two percent of the women in this study received mother-newborn SSC immediately after birth, and 48% experienced convention care after delivering their baby. In this study, mothers in the SSC group had completed lower levels of education compared to mothers in the routine care group; however, this difference was not associated with the outcomes assessed in this study when logistic regression analysis was applied. No relationship was observed between other maternal characteristics with SSC and routine care.

According to the results of the present study, contact through the skin between the women and their newborns after birth led to greater initiation of breastfeeding. It is not clear why SSC improved breastfeeding behaviors of healthy full term infants, however, similar findings have been reported in the literature [24]. The American College of Nurse-Midwives state that SSC helps infants smell and find the nipple so that breastfeeding will be initiated by them more rapidly and successfully [25]. This can be attributed to the high levels of catecholamine immediately after birth, which makes olfactory bulbs in the infant’s nose extremely sensitive to odor cues [26]. The results of the studies carried out by Moore and Anderson in USA [27], Khadivzadeh and Karimi in Iran [28], and Mahmood et al. in Pakistan [29] showed that early contact improved breastfeeding initiation and prolonged the duration of breastfeeding in infants. Early initiation of breastfeeding stimulates breast milk production, produces antibody protection for the newborn and its practice determines the successful establishment, longer duration of breastfeeding, and lower risk of neonatal mortality [30].

In their study, Essa et al., using the Infant Breastfeeding Assessment Tool (IBFAT), found that the SSC and control groups were statistically different in terms of the success of the first breastfeed rate [31]. However, the LATCH scale used in this study to assess the success of breastfeeding found no statistical difference between the two groups. This discrepancy could be due to a difference in the tools used to assess the success of breastfeeding.

Neonatal hypothermia is an important contributing factor to neonatal mortality and morbidity in both developed and developing countries; especially in developing countries [10]. The Maternal and Child Health Program by the WHO has issued guidelines for prevention of neonatal hypothermia as one of the elements of essential care in the newborn at birth and on the first day of life [32]. In the present study, 42% of the newborns who did not receive SSC care had hypothermia; however, just 2% of the newborns who received SSC developed hypothermia after birth. In their study on 160 term neonates in Iran, Keshavarz and Haghighi investigated the effects of kangaroo contact on physiological variables after cesarean section. In so doing, the neonates were randomly assigned into a SSC group and a routine care group. The newborns’ temperatures in both groups were measured half an hour after the cessation of contact. The mean temperature was significantly different in the SSC and routine care groups (36.8 °C and 36.6 °C respectively), and the mean temperature one hour after SSC was 36.9 °C, which was 0.3 °C higher than the mean temperature in the control group (푃 = 0.001) [33]. The results of a meta-analysis comprised of 23 studies indicated strong evidence of increased body temperature as a result of SSC. It is interesting to note that the ambient temperature did not influence the outcome of body temperature, as even in colder environments the body temperature of newborns who received SCC increased or at least remained unchanged [34]. Transfer of heat from the mother to the newborn facilitated by direct skin contact has been demonstrated to be at least as effective as incubator care for warming [35].

Assessing the effect of SSC on duration of the third stage of labor in the present study showed that the mothers who had SSC with their infant after birth had a shorter third stage in comparison with those who received routine care (6 min vs 8.02 min). Similar findings have been reported in a study carried out in Baghdad, Iraq by Mejbel and Ali to examine the effectiveness of SSC on the duration of the third stage of labor [36]. In an Egyptian investigation of low risk primiparous women who either received SSC or routine hospital care, the mean duration of the third stage of labor in the SSC group was significantly shorter (2.8 ± 0.85 min) than the routine care group (11.22 ± 3.33 min) (p < .01) [31]. Common practices used in the management of third stage of labor neither facilitate the production of a mother’s own oxytocin nor reduce catecholamine levels during the first minutes after birth, both of which can be expected to physiologically improve the new mother’s contractions and thus reduce her blood loss. The routine practice of separating mother and infant deprives the mother of important opportunities to increase her natural oxytocin levels [12].

The results of the present study need to be considered in the light of its limitations. In this study, there were no data on exclusive breastfeeding, and duration of breastfeeding was not assessed. In future studies, it would be beneficial to look at exclusive breastfeeding after discharge through a longitudinal study. The researcher of the present study was faced with some challenges in facilitating SSC for the mothers in the intervention group. This may have been because mothers in this study had low knowledge regarding SSC care, as a result of poor provision of health education at antenatal care units in primary health care center in Erbil: only 23.7% of visiting women receive education about infant care and breastfeeding [15]. Increased workload in the obstetric unit did not allow the researcher to continue SSC more than one hour after birth, although most of the mothers were very pleased and enjoyed the experience of SSC and wished to prolong its duration.

To reduce the current prevalence of high neonatal morbidity and mortality rate in Iraq, there is a dire need for simple and cost-effective prevention and (complementary) intervention methods that are easily accessible to mothers and can be applied immediately after birth. Mother and newborn SSC is a low-cost intervention that would be accessible, simple, and feasible for most mothers in developing countries. In order to accomplish this goal, the old paradigms of labor and delivery care need to be changed and immediate, uninterrupted SSC after birth should be practiced. Unlimited opportunities for SSC and breastfeeding promote optimal maternal and child outcomes. It is critical to provide all midwives in delivery rooms with continuous educational and training programs on how to implement SSC for all mothers. These changes directly support the millennium goals of improved maternal and child health.