This thesis investigated the influence on breastfeeding of uninterrupted naked body contact between mothers and their newborn. The study explored breastfeeding initiation practices at the time of birth and examined relationships between duration of naked body contact and a range of breastfeeding and maternal outcomes. There were four phases of this prospective, exploratory study. Phase 1 involved recruiting women (n = 100) who attended the public hospital antenatal clinic, were at least 36 weeks pregnant, intended to breastfeed, and had no aversion to holding their naked baby after birth. Participants provided demographic and antenatal information, a breastfeeding history and completed a standard questionnaire on breastfeeding confidence.
Phase 2 was an observation study of mothers from the recruited sample and their newborns (n = 78) for the first 60 minutes following birth. Events were recorded minute by minute on a prepared observation sheet and included placement of babies after birth, factors separating newborns from mothers, interruptions to naked body contact, newborn feeding behaviours, maternal action to assist babies in attaching to the breast, assistance received by mothers, and any routine medical or resuscitation interventions. Birth details were collected from medical records at this time.
Phase 3 involved postnatal observations of breastfeeding and structured interviews with recruited mothers (n = 96 out of 100) prior to discharge from hospital. A tool to observe maternal nurturing, positioning, attachment, breastfeeding, and maternal independence was developed and shown to be reliable. Mothers were interviewed to determine the extent of breastfeeding problems such as nipple pain and trauma, their experience of holding their naked baby at birth if this occurred, and perceptions of help and support to initiate breastfeeding. The final phase (Phase 4) followed mothers at 2 weeks, 3 months and 6 months postpartum. The telephone interview asked about breastfeeding duration and problems. Questionnaires relating to maternal breastfeeding confidence and perceptions of milk adequacy were repeated at 2 weeks and 3 months. Seventy-four percent (74%; 58 out of 78) of mother/baby dyads in the sample of observed births spent at least 30 minutes or longer together in naked body contact within the first hour after birth. While nearly all mothers experienced contact with their babies within the first minute after birth, less than half the mothers (42.6%; n = 26) who gave birth vaginally held their naked newborn on their bare chest immediately and remained together for 60 minutes. A further 46% (n = 28) held their babies in skin-to-skin contact for at least 30 minutes and seven did for less than 30 minutes or not at all. Four mothers (out of 17) who had a caesarean section held their newborn in naked body contact for at least 30 minutes of the first hour. A quarter of the vaginally birthed newborns (n = 16) and all babies born by caesarean section (n = 17) were initially separated from their mothers. Skin-to-skin contact was interrupted for several mothers (n = 14). Seven mothers and babies did not experience naked body contact within the first hour following birth. Babies who did not begin skin-to-skin contact with their mothers immediately after birth were most commonly placed on the resuscitation cot. In many cases no resuscitation action was required and babies were returned to their mothers within a few minutes. Interventions such as administration of oxygen and/or suction were carried out for two thirds of babies born by caesarean section. Babies were then dried, wrapped and placed with their mothers or placed in the humidicrib for warmth and later placed in skin contact with their mothers. Some babies were kept wrapped or taken to the ward nursery for routine procedures and assessment. Two thirds (n = 52) of infants in the present study commenced suckling within the first hour after birth. A quarter (n = 19) of babies initially separated began to suckle at the breast within the first 60 minutes after birth. Babies of multiparous women were significantly more likely to begin suckling within the hour (?² (1) = 10.01, p < .01). Twenty-seven percent (27%) of newborns were subjected to either oropharyngeal or nasopharyngeal suction soon after birth. Any form of suction administered had a negative effect on newborns achieving suckling during the first hour. A direct logistic regression model suggested that commencement of suckling within the hour was associated with four predictor variables: 1) duration of naked contact beyond 30 minutes; 2) baby’s chin nudging the underside of their mother’s breast; 3) ‘hands-on’ help that mothers received to position or attach their babies; and 4) no suction administered to babies (F (7, n = 78) = 36.25, p < .001). A significantly higher proportion of babies achieved suckling (81.6% versus 52.5%) within the first hour in the birthing room if mothers received ‘hands-on’ help to position or attach their babies. A greater proportion of babies achieved suckling (56% versus 27%) within the hour if mothers received ‘hands-on’ help only to attach their babies to the breast. However, mothers who received ‘full assistance’, i.e. to position and attach their babies in the birthing room, reported significantly lower breastfeeding confidence at 2 weeks postpartum compared to mothers who did not receive assistance (t (65) = 2.16, p < .05). Effective suckling observed in the postnatal period at around 48 hours was associated with the newborn infant’s body being stabilized against their mother’s body (?² (1) = 9.087, p < .01) and baby’s chin in firm contact with mother’s breast (?² (1) = 7.05, p < .01). A significant relationship was found between duration of skin contact greater than 55 minutes in the birthing room and no visible nipple trauma prior to discharge (?² (1) = 4.12, p < .05). The wide variation in practices observed during the first hour after birth suggests inadequate attention is given to protect and support the first breastfeed. Duration of naked body contact between mother and newborn in the first hour after birth along with instinctive positioning of the baby at the breast contributes significantly to newborn suckling ability in the first hour after birth and during the later postnatal period. The present study extends current understanding of how positioning and attachment is taught to mothers by incorporating principles of instinctive positioning seen in the birthing room to subsequent breastfeeds and ongoing management. Birthing room intervention of naked body contact between mother and newborn and careful well-documented observation of newborn feeding behaviour would be of practical benefit to identify problems/difficulties early and provide support and guidance to mothers and their newborns. Revisions for Baby Friendly Hospital Initiative (BFHI) best practice standards in ‘Steps 4 and 5’ to help mothers initiate breastfeeding and show mothers how to maintain breastfeeding are overdue and need to be addressed. The observation tools used in the present study inform best practice guidelines for timeframes to begin breastfeeding and assistance required. These tools would also be useful for auditing breastfeeding initiation practices in hospitals in relation to breastfeeding outcomes and sustained breastfeeding.