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Skin to Skin and Breastfeeding Success

Molly Gleason

Methodist College
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Purpose for the Review

The purpose for the review of literature was to retrieve evidence regarding breastfeeding

success rates after skin to skin contact between mother and infant immediately after delivery.

The research question for this review was: In newborns, what is the effect of skin to skin contact

on breastfeeding success rates when compared with no skin to skin contact?

Description of the Search Method

The search was conducted through EBSCOhost, which included CINAHL, Medline

Complete, and Cochrane Databases. The key phrases “skin to skin” and “newborn” were used in

the search mode “Boolean/Phrase” and included the subjects Clinical Queries, Publication Type,

and Journal Subset. The period of time covered was between 2007-2017 (current). Nursing

journals were reviewed to retrieve primary sources. This search initially yielded 2,356 articles

and was then limited by searching for full text articles and adding “quantitative” to the search

criteria, resulting in 1,332 articles. Inclusion criteria included primary, quantitative studies that

focused on the population of postpartum mothers and infants within the last seven years.

Primary, quantitative studies were chosen in which the population that participated in the

intervention (skin to skin contact) was compared to a control group (no skin to skin contact).

Exclusion criteria included qualitative data research studies, studies examining non-healthy

infants and mothers, and articles older than ten years. Following further review of the articles,

three quantitative studies were selected for this review.

Research Design

Bramson et al. (2010) examined the effects of skin to skin contact during the first three

hours following birth on exclusive breastfeeding during the maternal hospital stay using a

prospective cohort quality assurance intervention design. In the randomized control trial by
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Aghdas et al. (2014), the purpose was to evaluate the effect of mother-infant immediate skin to

skin contact on the mother’s self-efficacy and success in breastfeeding. In the cohort study by

Guala et al. (2017), the purpose was to examine skin to skin contact in the operating room after a

cesarean section and its relationship with the duration of breastfeeding.

Data Collection

Nineteen hospitals in San Bernardino and Riverside counties participated in the study by

Bramson et al (2010). The sample size included 21,842 participants who had delivered a healthy,

singleton infant between 37 and 40 weeks of gestation who were not separated for more than one

hour during the mother’s hospital stay. The research variable was the length of time the infant

spent skin to skin. The independent variables included the mother’s feeding-method of choice,

sociodemographic factors (including the mother’s primary language, race and ethnicity, age,

smoking status, and educational level), intrapartum variables (such as any analgesics or

anesthesia used), mode of infant delivery, and the length of time spent in skin to skin contact.

The dependent variable was the rate of exclusive breastfeeding during the maternal hospital stay.

The data were collected by both an interview and a data collection measurement form at baseline

hospital admission, the intrapartum period, and then the postpartum period at 1-15 minutes, 16-

30 minutes, 31-59 minutes, and 1-3 hours after birth.

The study by Aghdas, Talat, & Sepideh (2014) took place at the Omolbanin Obstetrics

Hospital in Mashhad, Iran. The sample size included 114 participants who were full-term,

healthy mothers who had a vaginal birth, and who intended to breastfeed the infant. The research

variable was the length of time spent skin to skin between the mother and the infant. Independent

variables included 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
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of the mother and infant in the first two hours after birth, and placing the infant under the radiant

warmer. The dependent variable was the rate of exclusive breastfeeding at 28 days postpartum.

The data were collected by a research questionnaire at the hospital, an Infant Breast Feeding

Assessment Tool at the hospital after the first breastfeeding session, and a home telephone

interview at 28 days postpartum.

The study by Guala et al. (2017) conducted their study in Italy with a sample size of 252

participants who were over 37 weeks of gestation with an infant APGAR score of seven or

greater at five minutes of life. The research variable was the length of time spent skin to skin

between the mother and the infant and how soon after delivery this contact occurs. The

independent variables were skin to skin contact with the mother, skin to skin contact with the

father, or no skin to skin contact (the infant heated under the radiant lamp). The dependent

variable was exclusive breastfeeding at hospital discharge, three months postpartum, and six

months postpartum. The data were collected by the Pediatrician at hospital discharge and home

telephone interviews at three months and six months postpartum.

Descriptive Data Analysis

Bramson et al. (2010) demonstrated that mothers who breastfed exclusively were more

likely to be Hispanic, have high school education, be a non-smoker, intend to breastfeed

exclusively, had a vaginal delivery, used non-central nervous system analgesia, and experienced

more than one hour of skin to skin contact during the first three hours after birth. Exclusive

breastfeeding at hospital discharge was found in 7,512 participants who had skin to skin contact

for more than 60 minutes versus exclusive breastfeeding in only 2,947 participants who had no

skin to skin contact (Bramson et al., 2010). It is evident that skin to skin contact following birth

increased the likelihood of exclusive breastfeeding.

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Aghdas, Talat, & Sepideh (2014) reported that skin to skin participants had higher rates

of breastfeeding self-efficacy and success at hospital discharge and 28 days postpartum when

compared to the routine care group (control group of no skin to skin contact). Successful

breastfeeding was found in 56.6% of skin to skin participants versus a success rate of only 35.6%

in the routine care group, indicating positive outcomes of skin to skin on breastfeeding success.

The study by Guala et al. (2017) reported higher rates of breastfeeding success in the

group of skin to skin contact with the mother when compared to skin to skin with the father and

no skin to skin contact (control group) at hospital discharge, three months, and six months

postpartum. At hospital discharge, 65% of infants who had skin to skin contact 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 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 (Guala et

al., 2017). This data infers positive outcomes of skin to skin on breastfeeding, both immediate

and long term.

Inferential Data Analysis

Bramson et al. (2010) reported that the longer the mother experienced early skin-to- skin

with the infant, the more likely she would breastfeed exclusively during her hospitalization.

Univariate logistic regression was used for the statistical analysis. It was found that the odds ratio
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of the likelihood of exclusive breastfeeding increased as the period of early skin-to-skin contact

increased, even when differences in hospital implementation of the intervention were controlled.

Aghdas, Talat, & Sepideh (2014) showed that immediate mother-infant skin to skin

contact lead to higher breastfeeding self-efficacy and success in mothers after the data were

analyzed using means, standard deviations, and proportions. T-test and chi square were used for

quantitative data analysis. Mann–Whitney test was used for parameters with non-normal

distributions. This data showed that the independent variable of skin to skin contact improves the

chance for successful breastfeeding, which was the dependent variable.

Guala et al. (2017) showed an association between skin to skin contact with the mother

and the exclusive breastfeeding rates at discharge, which was maintained at three and six months

postpartum. The statistical analysis was conducted and the differences were quantified with a

two-sample test for proportions, which calculated the confidence intervals. The linear trend was

maintained at each stage, showing a statistical association between skin-to-skin contact with the

mother and exclusive breastfeeding.

Application of Findings to Evidence Based Practice

This body of evidence indicates that skin to skin contact improves breastfeeding success

must be implemented into nursing practice. Policies and procedures must be created within

institutions to promote skin to skin contact after delivery. Education must be provided for

patients, staff, and providers on this intervention in order to be successfully carried out after

every delivery. These studies address the gap in nursing knowledge on the importance of skin to

skin contact on breastfeeding success.

Critical Analysis of Principal Topics

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Motivation for this body of research included the goal of Healthy People 2010 to increase

breastfeeding rates in infants (Bramson et al., 2010). The topic of research is a part of the World

Health Organization and UNICEF’s Baby Friendly Hospital Initiative (Guala et al., 2017). The

Academy of Pediatrics 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 first

hours after birth has been shown to be the best time to initiate breastfeeding while the infant is

alert (Aghdas et al., 2014). Skin to skin contact not only improves breastfeeding outcomes, but

also helps with infant temperature regulation, neonatal bonding, decreased crying, stabilization

of the infant cardiac and respiratory system, and microbial colonization (Guala et al., 2017). This

evidence of the positive influences of skin to skin must be taken into account when developing

hospital practices and policies.

Methods used to investigate the research question included cohort studies and a

randomized control trial. Interviews, questionnaires, and data collection tools were used to

gather the data.

The results of the studies showed an increase in breastfeeding success if the infant and

mother participated in skin to skin contact after delivery. Based on the research, a synthesis can

be made between skin to skin contact and breastfeeding success. These findings were expected

and agree with previous study results found in the literature review. The results of each study

were found to be both reliable which strengthens the evidence of the findings and implications

for nursing practice.

Ethical considerations of the studies included no conflicts of interest reported. The

studies minimized threats and bias to the internal validity of the studies by using measurable,

quantitative data and by using blind interviewers and research assistants. Skin to skin contact
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was not withheld for the purpose of the studies and was most often not performed due to

maternal or infant complications or parental refusal. However, only participants who had

received Baby Friendly Hospital Initiative-compatible information were included in the study by

Guala et al. (2017) and the lack of measurement of oxytocin in the study by Bramson et al.

(2010) affects the external validity of the findings.

Strengths included large sample sizes and a wide range of socioeconomic data. These

strengths can be related to nursing practice because of the wide range of socioeconomic

characteristics in patient populations. Aghdas et al. (2014) are members of the Student Research

Committee, School of Medicine, School of Nursing and Midwifery, and Women’s Health

Research Center, strengthening the confidence in the findings. The clinical qualifications of

Bramson et al. (2010) include instructors, professors, researchers, and the clinical director of the

Perinatal Services Network. Guala et al. (2017) members participate in the Department of

Pediatrics, Anesthesia and Resuscitation, Baby Friendly Initiative, and Department of Obstetrics

and Gynecology. These experiences increase the validity of the research findings. Limitations

discussed include the need to monitor these patients for an extended period of time to

determinate long term results by all three studies. In clinical nursing practice, breastfeeding rates

would need to be monitored up to at least one year. This extended research is logical and

appropriate for further follow up.

Each article provided a critical analysis of the research conducted. Each article was

organized, professionally written, and provided all necessary components. The articles were

easily retrievable and written at a level of understanding for nurses and healthcare personnel. The

results are credible based on the number of times the data were tested and found congruent. A
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CONSORT flow chart was used in the Aghdas et al. (2014) study which describes the 114

participants separated into 54 skin to skin contact participants and 54 in the control group.

Conclusion

In summary, the research has shown multiple benefits of skin to skin contact after

delivery, specifically in breastfeeding success rates and maternal confidence in her breastfeeding

ability. This meaningful evidence must be implemented into practice and policies within hospital

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

order to be successfully carried out after deliveries, though further research is needed on long

term breastfeeding success rates. 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 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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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

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

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