BREAST FEEDING INITIATION RATES

Breastfeeding Initiation Rates with Skin to Skin Contact

Amber Morin
University of South Florida

BREAST FEEDING INITIATION RATES

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Abstract

Breastfeeding is remarkably beneficial for both mother and baby. However, according to the
Center for Disease Control and Prevention (2014) only 18.8% of our nations infants are
breastfed under the current recommendations. Skin to skin contact has shown to be effective in
increasing the rate of breastfeeding. This project was conducted in order to increase the incidence
of skin to skin contact immediately after birth. Search engines used were CINAHL, Pubmed, and
National Guideline Clearinghouse. Based on randomized controlled trials, recommendations, and
discussion with stakeholders at Florida Hospital Tampa, the intervention of skin to skin contact
will be implemented and the probability of this intervention of increasing breastfeeding initiation
is very high.
Keywords: breastfeed, breastfed, initiation, and skin to skin

BREAST FEEDING INITIATION RATES

Breastfeeding Initiation Rates with Skin to Skin Contact

Breastfeeding is one of the most beneficial practices that can be implemented to increase
the health and well-being of infants and mothers. According to the U.S. Department of Health
and Human Services (2014), breast milk provides the newborn with hormones and antibodies
that protect infants from diseases such as asthma, leukemia, obesity, diabetes, ear infections,
diarrhea and vomiting, lower respiratory infections, necrotizing enterocolitis, and SIDS. Emily
Sullivan, a lactation specialist at Florida Hospital Tampa, stated breast milk provides the infant
with beneficial bacteria for immune protection and prepares the stomach for nutrition (personal
communication, February 16, 2015). According to the U.S. Department of Health and Human
Services (2014), breastfeeding can also increase infant-maternal bonding and protects the mother
from type two diabetes, certain types of breast cancer, and ovarian cancer. While breast feeding
is one of the most important nutritional decisions that can be made for infants, many infants are
not breastfed under the CDCs recommendations. In fact, according to the Center for Disease
Control and Prevention, in 2014 while 79.2% of US newborns were ever breastfed, the national
average for exclusive breastfeeding at 6 months (the CDCs current recommendation) was only
18.8%.The U.S. Department of Health and Human Services (2014) recognizes there are many
barriers to breastfeeding including sore nipples, low milk supply, engorgement, plugged ducts,
and latching difficulties. A method that can combat many of these barriers is the use of skin to
skin contact. According to Sullivan, skin to skin contact improves breastfeeding initiation rates,
maternal confidence, and provides many physiological benefits to infants including stabilization
of heart rate, improved breathing pattern and oxygen saturation, less cold stress, stabilization of
blood sugar, analgesia, increased brain development, decreased crying, calms mother and baby,
promotes bonding between mother and baby, and results in shorter hospital stays (personal

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communication, February 16, 2015). Skin to skin has improved initiation of breastfeeding and
maternal confidence can help women overcome barriers and continue to breast feed their infants.
Therefore, skin to skin contact can ultimately improve infants nutrition and outcomes and help
meet our national guidelines for breastfeeding. The PICOT question is as follows: In new
mothers how does the implementation of skin-to-skin contact immediately after birth compared
to standard practice affect the breastfeeding initiation within 48 hours of birth? The infrastructure
of Florida Hospital Tampa will allow this project to be successful. The infrastructure is
composed of nurses and physicians that will implement skin to skin contact. Nurses play a
crucial role in not only documenting skin to skin, but also educating mother and baby on how to
properly breast feed and implement skin to skin. Florida Hospital Tampa has already begun
utilizing skin to skin; therefore this intervention should be implemented successfully. This
project will help ensure everyone involved in mothers and infants care utilizes skin to skin
when possible.
Literature Search
Search engines that were used to find randomized controlled trials were CINAHL,
PubMed, and National Guideline Clearinghouse. Keywords used were breastfeeding, breastfed,
skin to skin, and initiation.
Literature Review
Three randomized controlled trials and one guideline were used to demonstrate the
effectiveness of skin to skin on breastfeeding initiation rates (refer to Literature Review table).
Aghas, Talat, & Sepideh (2014) conducted a randomized controlled trial to measure
breastfeeding success rates and self-efficacy in new mothers in regards to breastfeeding. The
SSC (skin-to-skin contact) group had the bare newborn lay on the mother's chest immediately

BREAST FEEDING INITIATION RATES

after the umbilical cord was cut. Weights, measurements, and vitamin K shots (routine care) were
postponed for at least two hours. The control group had weights, measurements, vitamin K shots,
and were placed under a radiant heater immediately after the cord was cut. Fifty-seven motherinfant pairs were randomly assigned to the control group, while 57 mother-infant pairs were
randomly assigned to the SSC group. The primary measurement of this study was maternal
breastfeeding self-efficacy at 28 days post-partum. The second measurement measured success
in first time breastfeeding and mean time of first breastfeeding initiation. Success in first time
breast feeding in the SSC group was 56.6% versus 35.6% in the routine care group (p=0.02).
Mean time of first breastfeeding initiation was significant between the two groups (p <0.0001).
This study concluded infants with skin to skin contact immediately after birth had more rates of
success with first breastfeeding and took less time to initiate breastfeeding. A weakness of this
study is follow ups did not occur after one month. It would be beneficial to see the longer lasting
effects of this study. Also, the sample size was small with 114 healthy, full-term mothers who
intended to breastfeed. This study will be a good resource because of the discussion of the
benefits of immediate skin-to-skin contact.
Dumas et al. (2012) looked at mother-infant interactions at post-partum day four. The
sample consisted of 176 mother-infant dyads. The women were randomly separated into one of
eight groups. The groups were skin to skin contact with swaddling or clothing in the maternity
ward; mothers arms group, separated by swaddling or clothing; the nursery group, separated by
swaddling or clothing; and the reunited group, again separated by swaddling or clothing. The
interventions in this study were skin to skin contact and rooming-in versus mother and infants
who were separated immediately after birth, then reunited two hours after birth. This study also
looked at skin to skin contact (infants being naked against the mothers skin) versus infants who

BREAST FEEDING INITIATION RATES

were clothed or swaddled. Infants who experienced skin to skin contact for the first two hours
after birth showed more successful breastfeeding results. At day four postpartum, skin to skin
contact pairs showed more successful attempts at latching (p=0.01) and less stimulation needed
by the mother (p=0.04). This study is helpful because it shows infants have more successful
breastfeeding outcomes when skin to skin contact occurs in the first two hours after birth. A
limitation of this study was a small sample group. Also, having eight separate groups made the
study confusing and hard to differentiate results.
Srivastava, Gupta, Bhatnagar, & Dutta (2014) compared the intervention of early skin to
skin contact for at least the first two hours after birth versus the control group of standard care
(infant is clothed, wrapped in a sheet, and placed next to the mother). The sample size consisted
of 298 mother-infant dyads who were randomly assigned to either the intervention or control
group. This study concluded that skin to skin contact led to better suckling competence based on
their IBFAT (infant breastfeeding assessment tool) score compared to the control group (mean of
9.55 vs. 6.77, respectively; p<0.0001). Results of successful breastfeeding were measured by
using the IBFAT and maternal satisfaction was measured in terms of breastfeeding at discharge.
Strengths of this study were better suckling competence in the skin to skin contact group and
retention of breastfeeding in the skin to skin contact group. A weakness of this study was not
describing or displaying their IBFAT more thoroughly. This study is helpful in showing positive
results of breastfeeding with early skin to skin contact.
The Academy of Breastfeeding Medicine recommendations include: all pregnant women
with be educated about benefits of breastfeeding and will be encouraged to exclusively
breastfeed unless contraindicated, skin to skin will be implemented immediately after birth if
mother and baby are stable, the baby will be dried off on the mother, the administration of

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vitamin K and prophylactic antibiotics will be delayed until after the first hour, the baby and
mother will be given the opportunity to breastfeed within the first hour, mother and infant will
remain together, using skin to skin whenever possible, including rooming in at night, and
mothers being properly educated on how to breastfeed (Philipp, 2010). Randomized controlled
studies included had many similarities to current guidelines. Aghas et al. (2014) instruct skin to
skin start as soon as the umbilical cord is cut and be continued for two hours. Dumas et al.
(2012) intervention group had newborns and mothers do skin to skin for the first two hours and
rooming in whenever possible. Srivastava et al. (2014) also had the intervention group do skin to
skin for two hours rather than one. All three randomized controlled trials also withheld
antibiotics, vitamins, and weights until after mother and baby did skin to skin for at least two
hours.
Synthesis
The implementation of skin to skin contact initiates higher rates of breastfeeding. All
three randomized controlled trials utilize skin to skin as the intervention compared to the control
group that does not utilize skin to skin. Aghas et al. (2014) measured success and mean time of
first breastfeed which yielded significant results, p=0.02 and p <0.0001, respectively. Dumas et
al. (2012) measured how many attempts at latch and how many times the mother had to stimulate
the baby at post-partum day four yielding results of p=0.010 and p=0.044, respectively.
Srivastava et al. (2014) measured suckling competence and how many infants were still
breastfeeding at day four postpartum and six weeks postpartum. At day four, the skin to skin
group displayed better suckling competence: p<0.0001. Also, at day four and six weeks
postpartum infants in the skin to skin group exclusively breast fed more than the control group,
86.1% vs. 66.9% and 85.2% vs. 63.6%, respectively.

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Therefore, all three randomized controlled trials demonstrate that skin to skin contact has
positive effects on breastfeeding initiation rates. Also, the Srivastava et al. study measured a
significant retention in breastfeeding in the skin to skin group (2014). These studies demonstrate
that this project should also yield positive results with the intervention of skin to skin contact.
More research should be conducted on barriers that mothers encounter when breastfeeding.
While a few of these studies researched maternal confidence, which may help women overcome
barriers, it is still not clear if this confidence can help overcome pain, latching problems, low
milk supply, etc.
Proposed Practice Change
According to Srivasta et al. (2014) skin to skin contact involves placing the naked infant
on the mothers bare chest immediately, or as soon as mother and baby are stable. This results in
improved breastfeeding initiation rates due to the infant being most awake immediately after
birth. Since infants are most awake, this is the optimal time to initiate breastfeeding. After about
two hours after birth newborns tend to fall asleep and opportunities for breastfeeding can be
missed (Srivasta et al., 2014). Therefore, Philips (2010) recommendation of the initiation of skin
to skin contact immediately after birth, continuing for one hour, and postponing medications and
weights should be employed.
Change Strategy
Promoting Staff Engagement
In order to promote involvement in this project, members of the team will be educated on
the positive impact skin to skin contact can have on patient outcomes. Further, meetings will be
held on a regular basis in order to educate the team on skin to skin and how to implement all
aspects of this project, address any concerns, and discuss progress.

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Approach to Change Consistent with the Organizational Culture

As stated earlier, Florida Hospital Tampa is committed to patient/family care. With this
vision in mind, team members will be reminded of this goal in order for everyone to see the
value skin to skin contact has on patient outcomes.
Model of Evidence-Based Practice Change
Many at Florida Hospital Tampa appeared unsure as to what their EBP model was.
Therefore, for this project the most appropriate model would be the Model for Evidence-Based
Practice Change. Since many of the staff was unaware of the model, this model will allow for a
more simplified, therefore effective guide to introduce staff to this project.
Roll Out Plan
Steps
Step 1

Step 2

Steps Defined by
Model
Assess the need for
change in practice

Locate the best

evidence

Steps Defined by
Time Frame
Project
The lack of infants
January 2015
being consistently
breastfed was
discovered by the
team. Internal
evidence was
collected by lactation
specialist at FHT. This
information was
compared with
external evidence.
CINAHL, PubMed,
January 2015and National
February 2015
Guideline
Clearinghouse was
used to locate
randomized controlled
trials and current
recommendations to
support the
intervention of skin to

BREAST FEEDING INITIATION RATES

Step 3

Critically analyze the

evidence

Step 4

Design practice
change

Step 5

Implement and
evaluate change in
practice

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skin contact.
Multiple studies were
read and compared.
Studies that most
closely matched this
projects intervention
were chosen. The
evidence was
synthesized.
Feasibility, benefits,
and risks were
considered. The
intervention is
deemed feasible,
beneficial, and of
little to no known
risk.
The proposed practice
change is to initiate
skin to skin
immediately, having
mother and baby
attempt breastfeeding
within the first hour,
withholding
medications and
weights until after this
first hour.
Based on appraisal of
randomized controlled
trials, the probability
of this projects
intervention of skin to
skin increasing the
initiation of
breastfeeding is high.
There would not be
any additional costs
by changing the
intervention to skin to
skin.

February 2015

February 2015March 2015

March 2015

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Step 6

Integrate and maintain Make stakeholders

March 2015change in practice
and team members
continued
aware of the positive
effects skin to skin
contact has on patient
outcomes.
Continually assess
progress of
intervention and
ensure all members
are participating in the
intervention.
Celebrate and praise
stakeholders and team
members for their
work in positive
patient outcomes.
(Melnyk&Fineout-Overholt, 2015).
Project Evaluation
Data to be collected for the intervention group: did initiation of skin to skin contact occur
immediately after birth, and if not chart reasons skin to skin did not occur; did skin to skin occur
for at least one hour; did infant begin breastfeeding within the first hour; were measurements and
medications withheld until at least one hour after birth in order for skin to skin to occur?
Breastfeeding assessments will be charted during feedings for both the intervention and control
group. The assessment will evaluate how long the infant takes to latch, the infants effectiveness
at latch, if the lips are flanged, if the infants tongue is down, and if there is a rhythmic sucking.
This assessment will be compared in the skin to skin group and the routine care group to evaluate
whether the intervention of skin to skin is significant. The parameters to indicate success of the
intervention would be if skin to skin contact occurs immediately after birth, or as soon as safe to
do so, whenever possible after birth, and if the infant shows success during breastfeeding
assessments. Breastfeeding would be deemed successful if the intervention group had at least a

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25% increase in breastfeeding initiation compared to the routine care group. The labor and
delivery nurse can help ensure skin to skin is started immediately and the mother/baby nurse will
conduct the breastfeeding assessments.
Dissemination of EBP
Since Florida Hospital is a large organization with twenty-five hospitals, there is
opportunity to reach out with many other facilities. To begin, our team can send a mass email to
other Florida Hospitals and to other organizations to see if they utilize skin to skin contact. If
facilities state they do not, Florida Hospital Tampa can correspond with them by email and in
person to aid in the process. In order to disseminate nationally, presentations can be held at
national conventions. All organizations should be reminded of our current national guidelines,
which include skin to skin contact to be used to aid in breastfeeding.

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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 randomized
control trial. Women and Birth, 27,37-40. http://dx.doi.org/10.1016/j.wombi.2013.09.004
Centers for Disease Control and Prevention.(2014). Breastfeeding report card. Retrieved from
http://www.cdc.gov/breastfeeding/pdf/2014breastfeedingreportcard.pdf
Dumas, L., Lepage, M., Bystrova, K., Matthiesen, A., Welles-Nystrom, B., &Widstrom, A.
(2012). Influence of skin-to-skin contact and rooming-in on early mother-infant
interaction: A randomized controlled trial. Clinical Nursing Research, 22(3), 310-336.
doi: 10.1177/1054773812468316
Office on Womens Health, U.S. Department of Health and Human Services.(2014). Why
breastfeeding is important. Retrieved from
http://womenshealth.gov/breastfeeding/breastfeeding-benefits.html
Office on Womens Health, U.S. Department of Health and Human Services.(2012). Common
breastfeeding challenges. Retrieved from
http://www.womenshealth.gov/breastfeeding/common-challenges/

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14

Philipp, B.L., (2010).Academy of Breastfeeding Medicine Protocol Committee. ABM clinical

protocol #7: Model breastfeeding policy. Breastfeeding Medicine, 5(4), 173-7.
Srivastava, S., Gupta, A., Bhatnagar, A., & Dutta, S. (2014). Effect of very early skin to skin
contact on success at breastfeeding and preventing early hypothermia in neonates.Indian
Journal of Public Health,58, 22-26. doi:10.4103/0019-557x.128160

Table 1
Literature Review
Reference
Aghdas, K., Talat, K.,
&Sepideh, B. (2014).
Effect of immediate and
continuous mother-infant
skin-to-skin contact on
breastfeeding selfefficacy of primiparous
women: A randomized
control trial. Women and
Birth, 27, 37-40.
http://dx.doi.org/10.1016/
j.wombi.2013.09.004

Aim

Design and
Measures
To measure
The intervention
breast
group utilized skin
feeding
to skin contact
success rates while the control
and selfgroup utilized
efficacy in
standard practice
new mothers. (receiving
medications,
weights, and being
placed under a
warmer
immediately after
birth.)

Sample
57 infantmother
dyads in the
intervention
group and
57 infantmother
dyads in the
control
group.

Outcomes/stati
stics
The primary
measurement of
maternal selfefficiency was
measured at 28
days postpartum. Mothers
showed
increased selfconfidence in
mothering
abilities in the
skin to skin
group. The
second
measurement
measured
success in first
time breast
feeding (p=0.02)
and mean time
of first breast
feeding

BREAST FEEDING INITIATION RATES

Dumas, L., Lepage, M.,

Bystrova, K., Matthiesen,
A., Welles-Nystrom, B.,
&Widstrom, A. (2012).
Influence of skin-to-skin
contact and rooming-in
on early mother-infant
interaction: A randomized
controlled trial. Clinical
Nursing Research, 22(3),
310-336. doi:
10.1177/1054773812468
316

Srivastava, S., Gupta, A.,

Bhatnagar, A., & Dutta,
S. (2014). Effect of very
early skin to skin contact
on success at
breastfeeding and
preventing early
hypothermia in neonates.
Indian Journal of Public
Health, 58, 22-26.
doi:10.4103/0019557x.128160

To observe
motherinfant
interactions
at postpartum day
four.

Mother and infants

were separated
into one of eight
groups. The most
pertinent groups
was the
intervention group
which utilized skin
to skin contact and
rooming-in,
compared to the
control group
which had mother
and infants
separated for at
least the first two
hours after birth.
Measurements
were conducted on
attempts at
latching and
amount of
stimulation needed
from the mother
for infant to breast
feed.
To measure
The intervention
breastfeeding group consisted of
success in
skin to skin
newborns
contact pairs and
and maternal the control group
satisfaction.
consisted of
standard care
newborns (clothed,
wrapped in a
sheet, and placed
next to the
mother).

15

176 motherinfant dyads

total.

298 motherinfant
dyads.

(p<0.0001).
At day four
post-partum,
skin to skin
contact pairs
showed more
successful
attempts at
latching
(p=0.010) and
less stimulation
needed by the
mother
(p=0.044).

The skin to skin

contact group
had better
suckling
competence
based on the
IBFAT tool
(p<0.0001) and
these mothers
had higher
maternal
satisfaction at
discharge.

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