There has been much research surrounding skin-to-skin care (SSC) in the immediate hours after birth, but far less examining the practice beyond the first hours and throughout the hospital stay. The effect of SSC shortly after birth is so powerful that it appears to positively influence the quality of mother-baby interactions 1 year later (Bystrova et al., 2009). SSC is defined as a mother holding her diaper-clad infant in a ventral position against her own bare skin with a blanket covering the dyad (Moore, Anderson, Bergman, & Dowswell, 2012). Existing literature supports that continuing SSC throughout the postpartum period is important to reduce the incidence of formula supplementation of breastfeeding infants as well as to enhance acquisition of the maternal role (Dalbye, Calais, & Berg, 2011; Moore et al., 2012; Thukral et al., 2012). Despite the benefits of SSC, separation of mothers and infants is common in many hospitals and infants are often swaddled in blankets and placed in bassinettes.
Little is known about mothers' feelings toward or barriers to holding their infants skin-to-skin during their hospital stay in the early postpartum period, nor about postpartum nurses' attitudes and beliefs regarding the practice. This study explored the beliefs about and perceived barriers toward SSC held by women who have recently given birth to healthy, full-term singletons, and also examined the understanding of the nurses working in the postpartum unit of the hospital in which the mothers gave birth. Identification of beliefs and perceived barriers held by both nurses and mothers is important in order to develop interventions to facilitate SSC. It is possible that increasing SSC in the postpartum period may decrease the frequency of formula supplementation during the hospital stay, a practice that is strongly associated with decreased breastfeeding duration (DiGirolamo, Grummer-Stawn, & Fein, 2008; Murray, Ricketts, & Dellaport, 2007; Parry, Ip, Chau, Wu, & Tarrant, 2013; Semenic, Loiselle, & Gottlieb, 2008).
Formula supplementation of healthy, term breastfed infants occurs for medical reasons such as hypoglycemia, hyperbilirubinemia, and excessive weight loss, and for nonmedical reasons such as maternal perception of insufficient milk supply, infant crying, maternal fatigue, and mother/baby separation. SSC has been shown to facilitate neonatal thermoregulation, conserve energy, regulate blood sugar, and improve the quality of breastfeeding, all of which may reduce the medical indication for supplementation (Hung & Berg, 2011; Gartner, et al., 2005; Moore et al., 2012). SSC also reduces infant crying (Dalbye et al., 2011; Moore et al., 2012), which mothers often perceived as hunger. A recent study concluded that SSC in the postpartum period may also reduce the incidence of postpartum depression, a condition that adversely affects mother/baby bonding, interaction, and quality of life (Bigelow, Power, MacLellan-Peters, Alex, & McDonald, 2012). SSC can be used as an intervention to overcome breastfeeding difficulties (Chiu, Anderson, & Burkhammer, 2008; Svensson, Velandia, Matthiesen, Welles-Nystrom, & Widstrom, 2013). It is interesting to note that in the study of all other mammals, separating the infant from the mother would be considered an intervention to study the impact of stress on the newborn, whereas in human studies, keeping mother and baby skin-to-skin is considered the intervention. Removing infants from their mothers is associated with a marked increase in autonomic activity and decrease in quiet sleep (Morgan, Horn, & Bergman, 2011).
The literature suggests that some of the barriers to SSC are concerns about maternal modesty (Moore & Anderson, 2007; Morrison, Ludington-Hoe, & Anderson, 2006) and infant safety (Mahlmeister, 2005). The modesty issue is especially relevant in the context of the frequent interruptions typically seen during the postpartum stay (Morrison et al., 2006). These concerns may impact SSC, breastfeeding efficacy, and amount of breastfeeding. Hospital practices including unnecessary supplementation often have a negative impact on breastfeeding success (DiGirolamo et al., 2008; Semenic et al., 2008; U.S. Department of Health and Human Services, 2011; United States Breastfeeding Committee , 2010). Despite the risk, supplementation of breastfeeding infants is common.
The conceptual framework for this study was Mercer's Becoming a Mother midrange nursing theory (Mercer, 2004). Mothers study their infants' responses to themselves and others, and use trial and error to learn to comfort and care for their infants (Meighan, 2010). The calming interaction of SSC during the immediate postpartum facilitates these interactions and promotes maternal confidence, competence, and attachment. SSC quite literally removes barriers between mother and baby, enhancing interaction and promoting calm. Additionally, Mercer emphasized that the care a mother receives can have long-lasting impact; thus, nurses may help mothers develop in their roles by promoting SSC during the postpartum stay.
Study Design and Methods
This mixed methods study used both a survey tool and focus groups to gain qualitative understanding of mothers' and nurses' perceptions.
Instruments
Based on the literature, we developed two data collection tools to assess attitudes, beliefs, and perceived barriers to SSC for nurses and mothers. The survey for new mothers included questions regarding maternal age, parity, baby's age, mode of birth, feeding intention, feeding status at time of discharge, race/ethnicity, and level of education. Survey questions for the nursing staff included level of education, experience, primary shift worked, and maternal status. Both were self-administered paper questionnaires completed voluntarily. The surveys had three parts. The first asked respondents to rate their beliefs concerning the importance of SSC during the hospital stay using a Likert scale ("strongly agree" to "strongly disagree"), the second asked respondents to check "yes" or "no" as to whether visitors in the room, feeling groggy, lack of awareness of SSC importance, modesty concerns, inconvenience, or other presented barriers to SSC, and the third listed the aforementioned issues and asked respondents to rank the top three in terms of their barrier to SSC. The surveys took respondents less than 10 minutes to complete. No respondent identifiers were collected.
Sample
Nurses working on the postpartum unit of an urban academic medical center in the Mid-Atlantic region of the United States were invited to complete the survey. Mothers who gave birth in that same hospital within the last 30 days were recruited from a support group for postpartum mothers and a hospital retail boutique frequented by many of the mothers.
Methods
The principal investigator conducted focus groups with two groups of nurses and one group of mothers. Members of the focus groups were asked the same questions that were on the paper survey. There was discussion among the group members about SSC, the barriers to the practice, and, in the mother group, feelings about SSC. Focus group members were also asked how they would feel about having a protected "quiet time" with limited visiting hours and minimal interruptions during the hospital stay. Institutional Review Board approval was obtained prior to study initiation.
Results
Surveys of Nurses
Fourteen nurses completed the nurses' assessment survey. All agreed or strongly agreed that SSC offered benefit to mothers and babies during the hospital stay. None of the nurses responded that mothers and their babies spent enough SSC time during the hospital stay. Two (14.3%) did not agree that hospital staff encouraged SSC, whereas 12 agreed (71.4%, n = 10) or strongly agreed (14.3%, n = 2) that hospital staff encouraged SSC. All but two disagreed or strongly disagreed that mothers were aware of the importance of SSC.
Table 1 shows the responses from the nurses about barriers to SSC. In addition, nurses wrote in free text such as visitors in the room, others wanting to hold the baby, mothers not understanding the importance, and maternal grogginess were identified by a strong majority. Maternal modesty was the only listed barrier that was not selected by a majority of nurses, although it is difficult to distinguish that from concern about visitors in the room.
Nurses were also asked to rank the top barriers to SSC during the hospital stay. The top four were visitors in the room (92.8%), others wanting to hold the baby (71%), mothers not knowing the importance (50%), and grogginess (43%).
Surveys of Mothers
Surveys were completed by 15 mothers, all of whom had given birth between 3 and 30 days prior. All agreed (13.3%, n = 2) or strongly agreed (86.6%, n = 13) that they spent enough time SSC during the hospital stay. All agreed (6.6%, n = 1) or strongly agreed (97.3%, n = 14) that SSC during the hospital stay was important. One mother (6.6%) disagreed that the nursing staff encouraged SSC, whereas the remaining mothers agreed (6.6%) or strongly agreed (86.6%) that the staff encouraged SSC. Most mothers did not identify barriers to SSC; however, those that did rated others wanting to hold the baby (20.1%), grogginess (13.4%), and visitors in the room (6.7%) as barriers (Table 7).
Focus Groups of Nurses
There were two small focus groups with postpartum nurses, one with three nurses and one with five. In both, "visitors in the room" and "others wanting to hold the baby" quickly emerged as themes. One nurse offered, "visitors in the room impact breastfeeding, as well. Sometimes hours and hours go by and the mothers won't feed their babies or pump or anything because people are there." The other nurses verbalized agreement, but found the patients' desire for visitors to be understandable. "It's healthy and it's normal. They want the attention."
When asked if they thought that an afternoon quiet time during which visitors were restricted and care was planned to allow mothers uninterrupted time with their babies, one group of nurses responded enthusiastically. They expressed that the quiet hours would provide time for them to do the tasks that need to be done away from the bedside and that mothers would benefit from the rest. The other group of nurses, however, delved into logistics that would make protected time challenging. "Their rooms are like revolving doors with the hearing screening, and environmental coming in and dietary...There's so much to do. When can you fit it in?" Another nurse agreed and observed, "It would have to involve a complete change in the way we do care."
Focus Groups of Mothers
This "complete change" might be welcomed by new mothers. One new mother expressed, "From seven in the morning until five in the afternoon people came in all the time. People came in to clean the room, clean the bathroom, to check on me and someone else to check on the baby. Every fifteen minutes someone different would come in. I could never relax. It was exhausting. It was stressful. I couldn't relax." The theme of not knowing when someone would enter the room came up several times, sometimes related to visits from staff and other times related to sharing a room. "We were in a double room. There were always people around. It is harder (to be skin to skin) when there are other people coming in. Private rooms will help." Another mother mentioned that visitors and interruptions impacted not only SSC, but breastfeeding, as well. "Now I feel like I can just feed anywhere. But then, it was all new, and I didn't feel comfortable with other people around." Nonetheless, mothers did verbalize that they enjoyed SSC with their infants. Stated one mother, "I loved it. It was the best. It soothed him and it soothed me, too."
Asked how they would feel about an afternoon quiet time, mothers responded positively. "I think if people knew ahead of time how you would feel after you have the baby, that would change everything. I thought I would want everyone there-I pictured a room full of visitors. But really, when the time came, I didn't feel like entertaining. I think now of all the people I visited in the hospital when they had their babies and I am sorry that I did that to them."
Clinical Nursing Implications
All of the nurses indicated that SSC was important for both mothers and infants and identified visitors in the patient room and others wanting to hold the baby as barriers to the practice. This information is especially important because hospital visiting hours have become more liberal in recent years, increasing patients' access to friends and family, but decreasing time alone with their infants. Some hospitals have recently instituted "nap time" or quiet hours in the afternoon during which they discourage visiting and cluster care to allow mothers and babies uninterrupted time together. It would seem, based on the results of this study, that quiet hours might be welcomed by new mothers. Nurses can use the information in this study to help alter policies in their institutions.
Morrison et al. (2006) observed the number of times mother/baby dyads were interrupted by visitors, staff, or phone calls during the first postpartum day and found that mothers had more time with others in the room and/or on the telephone than they did alone with their infants. In a recent study by Albert and Heinrichs-Breen (2011), breastfeeding mothers who used a privacy sign on the door of their hospital room experienced significantly fewer interruptions. Although the number of breastfeeds did not differ from those without the privacy sign, mothers were significantly more likely to characterize feedings as "successful." This feeling of success may be related to having the privacy needed for the mother to feel safe, enabling oxytocin release for the milk-ejection reflex (Bruckmaier & Wellnitz, 2008; Odent, 2012).
The benefits of SSC are known to both nurses and mothers. Standard practice at the study birth hospital is to place mother and infant skin-to-skin immediately after birth until after the first breastfeeding or for at least 1 hour should the mother decide not to breastfeed. However, postpartum unit policies are not standard. Modified visiting policies coupled with clustered nursing care allowing mothers and babies uninterrupted time together may increase SSC. Providing door hangers that mothers can use when they do not want to be disturbed may allow them to relax, free from fear of interruption, allowing the oxytocin to flow as they get to know their babies and explore their new maternal role. By protecting privacy, mothers could feel more successful in their breastfeeding, which could also help with establishing maternal role development.
Safety fears related to medicated or exhausted mothers practicing SSC present a challenge. Recognizing that partners can also hold infants skin-to-skin and actively encouraging them to do so may address this concern. Several garments are designed to allow mothers to wear the baby skin-to-skin without the risk of infants falling. One Midwestern hospital using such a garment for several years found no safety issues and reported an increase in SSC and satisfaction with breastfeeding and a significant decrease in infant crying (S. Houston, personal communication, November 12, 2011). Perhaps a protected "afternoon quiet time" would decrease maternal fatigue, increasing safety, as well. All of these practices would provide nurses the opportunity to reinforce the importance of SSC throughout the postpartum period, likely decreasing the gap between nurses' and mothers' perceptions about what constitutes "enough" SSC.
This study was limited by small sample size. Further research related to barriers to SSC and overcoming such barriers is needed. Some hospitals, including the study hospital, have recently instituted visiting policies designed to decrease interruptions for mothers and babies. Research is needed to learn patients' experience of these more restrictive visiting policies and to discover what if any outcomes related to SSC and supplementation of breastfed infants may be associated with the changes. Research related to safety, satisfaction, and outcomes related to use of garments that facilitate SSC would also be welcome.
Women develop into motherhood as they interact with their infants, learning their cues and responding with behaviors that deepen attachment (Mercer, 2004). SSC enhances the dance between mother and child, promoting physiological stability and calm in the infant, confidence and competence in the mother. Identifying barriers to SSC and intervening to reduce them may have implications for both maternal role development and feeding success, thus positively impacting long-term health of mother and child.
Suggested Clinical Nursing Implications
* Modify visiting policies and cluster care to allow mothers and babies uninterrupted time together
* Provide door hangers that mothers can use when they do not want to be disturbed
* Consider a garment that facilitates SSC
* Institute afternoon nap time for mothers to decrease fatigue and address safety concerns
MCN Paper of the Year Awards
MCN is delighted to announce the winners of the 2013 MCN Research Paper of the Year and the 2013 MCN Practice Paper of the Year awards. These articles were chosen from all articles (except those written by Editorial Board members, who are not eligible for these awards) by a vote of the MCN Editorial Board. These winners represent excellence in content, and help to continue MCN's commitment to improve nursing knowledge and evidence-based practice.
2013 MCN Practice Paper of the Year
Jennifer Gaye Hensley, Bonita A. Shviraga. Metastatic Choriocarcinoma in a Term Pregnancy. Published in MCN October 2013 MCN In Advance, Published Ahead of Print.
Dr. Hensley is an Assistant Professor, School of Nursing, University of Colorado, Denver, Denver, CO. Dr. Shviraga is a nurse midwife at Aurora Midwives, Aurora, CO.
2013 MCN Research Paper of the Year
Madalynn Neu, Joann Robinson, Sarah Schmiege. Influence of Holding Practices in Preterm Infant Development. Published in MCN May/June 2013, vol 38 no 31
Dr. Neu is an Assistant Professor, School of Nursing, University of Colorado, Aurora CO. Dr. Robinson is a Professor at the University of Connecticut. Dr. Schmiege is an Assistant Professor at the University of Colorado, Department of Biostatistics.
These authors will receive a cash award and a certificate of achievement. Congratulations!
References