Setting
This study was carried out in a public second-level hospital in the rural community of Montemorelos, in the state of Nuevo Leon in Mexico during 2016. Montemorelos is a community of 60, 829 inhabitants [11] that gave birth to 2111 live newborns in 2015 [12], obtaining an estimated birth rate of 28.81 per 1000 inhabitants. From the total births of that year, 972 (46%) took place at the study hospital.
The hospital’s labor and birthing area consist of two adjacent rooms with three beds for labor, one birthing bed, one infant radiant warmer, and one recovery bed for the immediate puerperium. As a second-level hospital, all high-risk pregnancies and all women in preterm labor (< 37.0 weeks of gestation) were referred to another tertiary level hospital in the city of Monterrey, Nuevo León, Mexico, thus only non-complicated full term pregnancies were included in the sample.
Routine care before our study
Before our intervention, the customary practice after birth was to place the newborn in the infant radiant warmer where they were dried, stimulated and assessed by either a pediatrician, a pediatric resident or a medical intern under supervision. Apgar scores were recorded during this time. After determining that the infants required no further reanimation, the nursing staff performed ophthalmic prophylaxis, application of vitamin K, identification of the child with a bracelet, obtained the fingerprints for the birth certificate, and recorded their weight and measurement. Afterwards, the newborns were wrapped in a warm cloth and were briefly introduced to their mothers before they were taken to the nursery. At the nursery, the babies were laid in an incubator where they stayed for at least two hours as they transitioned to extrauterine life. While in the incubator, the neonates were given either dextrose 5% or infant formula for their first feed, depending on the attending physician’s preferred choice. After this period, they were taken out, bathed and dressed to finally be taken to their mothers’ side, where they would start breastfeeding. Like most hospitals in Mexico, our hospital has no midwives, hence, all activities, education and care are performed either by the nursing or medical staff. The lack of midwives in Mexico responds to their continued relegation during the twentieth century, which limited “traditional” midwives to practice only in indigenous communities and not as part of the healthcare system [13].
Proposed change in practice
A thorough discussion with all the involved hospital departments was done before hand, and the study was approved by the hospital’s ethics and research committee. Given that this was a radical change in a practice that had been in place for years, our proposal was met with some resistance. Even though the procedure on how to perform SSC has been very well documented [14], a compromised decision was finally reached with an agreement upon the steps on how SSC and early breastfeeding could be performed at our site, with the goal of achieving immediate, continuous, and uninterrupted SSC as per the algorithm described by Brimdyr et al. [15]. The steps are described as follows (Fig. 1):
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The attending pediatrician or pediatrics resident or intern under his supervision receives the newborn in the infant radiant warmer.
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While being on the infant radiant warmer, the newborn is dried, assessed and examined. Apgar scores are determined within the first and fifth minute of life and recorded. (This means all newborns had a delay of up to five minutes before SSC was initiated.)
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The naked newborn is then placed directly on the mother’s bare chest, with the mother’s hand holding the newborn’s back and both are covered with a sterile cloth for temperature regulation.
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The newborn remains on the mother’s chest in the birthing room while the obstetrician finishes the mother’s post-birthing care.
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The mother and the newborn are then transferred out of the birthing room into the recovery room without removing the newborn from the mother’s chest.
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Once in the recovery room, with uninterrupted SSC, mothers are encouraged to initiate breastfeeding as soon as possible.
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The newborn remains on the mother’s chest until both are transferred to the maternity ward, where the infant is finally separated from the mother and transferred to the nursery.
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At the nursery, the ID bracelet is placed, the newborn is measured, weighed and bathed, and receives ophthalmic prophylaxis and application of vitamin K.
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The newborn is finally dressed and brought in a crib to the maternity ward to allow rooming-in with the mother.
Educational intervention
A two-step educational intervention was designed to institute the changes proposed. First, all staff members assigned to the labor and birthing service were trained by two senior pediatrics residents (GZ, AR). A total of 36 subjects (6 residents, 5 senior medical students, 7 nurses, 10 nursing interns, and 2 area directors) received a one-time 45-min lecture that covered the benefits and methodology of SSC and early breastfeeding and incorporated recommendations based on the baby friendly hospital initiative [16]. Sessions consisted of several training groups divided into one morning group, one evening group, three night-groups and one weekend group, covered within a one-week period.
The second part of the educational intervention consisted in providing education to the expecting mothers. Currently, all pregnant woman affiliated with the Mexican government’s healthcare insurance plan Seguro Popular are required to receive several educational sessions throughout their pregnancy covering different health-related topics. Routinely at our hospital, all women who reach 36 weeks of gestation are gathered to receive an educational session during that week, and these sessions are held on a weekly basis. For the second step of our intervention, we included during the session a 45-min lecture offered by the head of the pediatrics department (MV) where the study was introduced, and the benefits of SSC and early breastfeeding discussed. Time was allowed for the expecting mothers to ask any questions, and after the session, all women who attended were asked to participate in the study, and if agreed on, consent was obtained.
The techniques used during the lectures, for both health personnel and pregnant women, were audiovisual presentations through PowerPoint®.
Timeline of the study
Pediatrics residents in Mexico perform a 4-month rotation in a rural hospital as part of their training during their senior year of residency. The study hospital’s education department asks that residents develop a quality improvement project during their rotation as part of their work. The present study was the result of such project undertaken by two senior pediatrics residents (GZ, AR) during their rotation from March 2016 to August 2016. During the first month of their rotation, the study was designed, and the first step of the educational intervention was performed. The second step of the intervention started on the last week of March and continued through the three remaining months of their rotation. The study was limited in time, as results needed to be presented by the end of their rotation. Thus, a follow-up time of three months was only feasible.
Variables analyzed
The time of onset of the SSC, its duration and the time of initiation of breastfeeding from the moment of birth were recorded by nursing staff in the newborn’s chart. The data was extracted by one of the researchers (LS) and analyzed by another (JR). Variables were measured only in those births who received SSC and early breastfeeding, as the rest received standard care and the variables could not be measured. No information regarding breastfeeding initiation or time of onset before our study were available. The included population for the study were low risk full term pregnancies born through vaginal births (instrumented births included). Premature births, cesarean births, and newborns requiring advanced neonatal resuscitation were excluded.
Statistical analysis
In light of the characteristics of the study, a descriptive analysis was performed to describe the characteristics of the births. Only those births who received SSC and early breastfeeding were analyzed using ANOVA tests with Tukey post hoc tests for multiple comparisons to assess change in the time of onset of the SSC, its duration and the time of initiation of breastfeeding through the three months of duration of the study. ANOVA tests were used to assess potential confounders (month of the study, the age of the mother, gravidity, and gestational age at birth). Statistical analysis was performed using the R software v. 3.0.2® [17] at the 95% confidence interval.
