PhD in Nursing Science Program

Elizabeth R. Moore

Randomized Controlled Trial of Early Mother-Infant Skin-to-Skin Contact and Breastfeeding Success


Background:  Early skin-to-skin contact is the placing of the naked infant prone on the mother's bare chest at birth or soon thereafter. The hypothesis underlying skin-to-skin contact is described in animal studies wherein the innate behaviors of neonates to survive are habitat dependent. In mammalian biology, maintenance of the maternal milieu following birth is required to express innate behaviors from the neonate and the mother that lead to successful breastfeeding, protect the mother from hemorrhage, and promote maternal attachment behaviors. Infant separation from this milieu results in protest-despair behavior. Mother-infant separation post-birth has been definitively documented in the rodent literature to compromise important adaptive behaviors, in particular responsivity to stress, across the life span. In humans, routine separation post-birth is unique to the 20th century. This practice is divergent from evolutionary history in which survival depended on close and virtually continuous maternal contact; the possibility of harmful effects of separation in the human newborn has not been systematically evaluated. Separation of mothers and their neonates has become standard practice. Concomitantly, there has been a widespread decline in breastfeeding, which is of major public health importance. Instinctively and biologically triggered behaviors soon after birth that lead to pain free and successful breastfeeding are remarkably fragile and easily disturbed. The use of maternal social, psychological and cultural variables to predict breastfeeding duration has been criticized because important biological components have not been considered. Women often modify their breastfeeding behavioral intentions based on their infant's performance at the breast. The infant's ability to establish effective breastfeeding is dependent upon providing the appropriate environment for these innate behaviors to be expressed. 

Purpose:  The purpose of this study was to evaluate the effects of an intervention based on human ethology, uninterrupted maternal-infant skin-to-skin contact in the first 1 to 3 hours postbirth, compared to standard care, holding the infant swaddled in blankets for 1 to 11/2 hours, on breastfeeding outcomes up to one month postbirth.

Hypotheses:  Hypotheses 1. Infants receiving uninterrupted skin-to-skin contact 1 to 3 hours post birth compared to infants receiving standard swaddled contact will: a) Demonstrate increased breastfeeding status (that is more exclusive breastfeeding); b) Gain more weight when controlling for formula supplementation by postpartum day 14; and c) Demonstrate earlier sucking competence.

Hypothesis 2. Mothers of infants with earlier sucking competence will have: a) a perception of higher milk volume; b) a decrease in the number of breastfeeding problems; c) a perceived increase in breastfeeding behavioral control; and d) an increased sense of parenting competence.

Hypothesis 3. Mothers who have an increase in perceived breastfeeding control will improve breastfeeding status.

Design:  A prospective, randomized 2-group experimental intervention design was used for this study with 20 healthy primiparous mother-infant dyads (10 in the intervention group and 10 in the control group).

Multiple measures, on days 1, 7, 14 and 30 postbirth, were obtained of the primary outcome variable, breastfeeding status or exclusivity using the Index of Breastfeeding Status. The time of effective breastfeeding, when the infant was considered to be suckling competently, was evaluated using the Infant Breastfeeding Assessment Tool. Infant weights were obtained on postpartum day 14 to obtain an indirect measure of infant suckling competence, and maternal milk transfer. The amount of any supplemental formula was also documented. At 30 days postbirth, the mothers were asked to identify the antecedents of their perception of the adequacy of their milk supply (using the Infant Satiety subscale of the H & H Lactation Scale), the number and severity of breastfeeding problems encountered (using the Breastfeeding Experience Scale). They were also asked to describe their breastfeeding self-efficacy (using the Breastfeeding Control subscale) and their confidence in their ability to be a good parent (using the Parenting Sense of Competence Scale). Each hypothesis was statistically tested for significance.

Results:  Results from this randomized clinical trial demonstrated that infants who were held skin-to-skin by their mothers soon after birth were able to suckle more competently during their first breastfeeding than infants who were held swaddled in their mother's arms. Infants who were held skin-to-skin established effective breastfeeding sooner than infants who were held swaddled during the first few hours postbirth (hypothesis 1c). Infants of mothers with erect nipples were also able to suckle more competently than infants of mothers who had flat nipples or nipples that would erect minimally with stimulation.

Mothers of infants who were able to establish effective breastfeeding sooner postbirth reported fewer breastfeeding problems during the first postpartum month (hypothesis 2b). Mothers with fewer breastfeeding problems during the first postpartum month had more breastfeeding confidence, commitment, and satisfaction at one month postbirth. Mothers with fewer breastfeeding problems also had a perception of higher milk volume and breastfed more exclusively. Mothers who were breastfeeding more exclusively at one month postbirth intended to breastfeed longer than those who were partially breastfeeding, and became more confident about their ability to successfully breastfeed during the first postpartum month than they were prenatally (hypothesis 3).

Hypothesis 1a was not supported. Skin-to-skin contact did not exhibit a direct effect on breastfeeding exclusivity, but it did influence exclusivity through the number of breastfeeding problems. Hypothesis 1b was also not supported. There were no significant between group differences in infant weight on day 14 postbirth. Hypotheses 2a, c and d were also not supported. Earlier infant suckling competence did not exhibit a direct effect on the mother's perceptions of the adequacy of her milk supply, breastfeeding, or parenting confidence. The number of breastfeeding problems, rather than the time of effective breastfeeding, was the central concept in this study, linking when the infant was considered to be consistently suckling competently to all the other outcome variables except parenting competence. Early skin-to-skin contact has a direct effect on the success of early breastfeedings, such as the time postbirth when the infant is considered to be suckling competently, but does not have a direct effect on more long term measures, such as the exclusivity of breastfeeding at one month postbirth.