INTRODUCTION:

“A newborn baby has only three demands. They are warmth in the arms of its mother, food from her breast and security in the knowledge of her presence. Breast feeding satisfies all the three.”¹Grantly Dick-Read

First few hours of life is a crucial period for the mother and the newborn for developing a successful mother infant relationship. Animal studies have shown that innate behaviors of the newborn which are necessary for the survival are habitat dependent. When the newborns are kept in the natural habitat that is in skin to skin contact with the mother immediately after the delivery there is successful adaptation of the newborn to the life outside the womb. The early mother newborn contact will foster the mother newborn attachment process at the earliest thereby enhancing the bonding between mother and her newborn. This practice also promotes immediate breast feeding as it takes an advantage of newborn’s early alertness and innate behavior to latch on to the breast within the first hours of life without particular assistance. This is the optimal time for neonate to initiate breastfeeding behaviors such as rooting and suckling, as they are most responsive to tactile, thermal, and odor cues from their mothers.²

NEED FOR THE STUDY:

Early skin-to-skin contact (SSC) is the placing of the naked neonate prone on the mother’s bare chest at birth or soon afterwards. Skin to skin contact is a powerful stimulant and through sensory stimuli such as touch, warmth, and odour stimulates the release of maternal oxytocin, causing rise in the skin temperature of mother’s breast, providing warmth to the infant. Kangaroo care (KC) method was the first introduced skin to skin contact for preterm infants in Bogota, Colombia to improve the physiological, cognitive and emotional aspects of development. Later this form of skin to skin contact was successfully implemented not only for the preterm babies but also for term babies.²

A parallel randomized controlled trial was conducted among 116 mothers and their full term infants to assess its effectiveness on maternal postpartum depressive symptoms, mental health, physical health, mother infant bonding, and infant outcomes suchas behavior, physical health and general development. Mothers with their newborn in the study group was requested to provide daily at least one continuous hour of skin to skin contact to their infant. The intervention started immediately after birth and lasted for 5 weeks. Mothers in the control condition was asked to provide the routine care. Maternal and infant outcomes were measured at 2 weeks, 5 weeks, 12 weeks and 1 year after birth. The study concluded that skin to skin contact is effective in low risk mother infant dyad on short term and long term basis.³

A study was conducted to determine the effectiveness of extra contact behavior on mother baby contact behavior among three groups, in which the first group had extended contact (kangaroo care for 60 minutes immediately after birth) and nurse concerned with advising and supporting mother, second group had extended contact and nurse concerned with nursing of newborn and third group had limited contact ( mother holding the baby for five minutes immediately after the birth) and nurse concerned with nursing of newborn. The findings revealed that there was no significant difference between first and second group but both were significantly different from third group. The mothers in group one and two showed more contact behavior such as rubbing, petting, rocking and holding the infants in arm and or against the body and had only fewer non-contact behaviors.⁴

A study conducted among postnatal mothers on the importance of immediate postnatal contact and its effects on breast feeding, where the early contact group had unwrapped babies against bare chest immediate postpartum. The findings of the study indicated that the women in the early contact group were successfully breast feeding at two months and the women in the control group were partially breast feeding. The study showed that early skin to skin contact had short term outcomes like primiparous women holding and nursing bare infants which gave them contentment, pleasure, excitement and tears of happiness and long term outcome of increased duration of breast feeding.⁵

Healthy full term infants employ a species specific set of innate behaviors immediately following delivery when placed in skin to skin contact with the mother. They have a heightened response to odor cues in the first few hours after birth and they localize the nipple by smell. This sensitive period predisposes mothers and infants to develop a synchronous reciprocal interaction pattern which promotes bonding, provided they are together and in intimate contact. Neonates who are allowed uninterrupted skin to skin contact immediately after birth and who self-attach to the mother’s nipple may continue to nurse more effectively.⁶

In present times the birth process has become a medical procedure. Once a newborn is delivered, it is tended to by healthprofessionals who provide medical care for the newborn apart from the mother. Often, newborns are removed from the mothers for cleaning, weighing, assessment and for artificial nourishment. This is physiologically and emotionally disruptive to a newborn who has been securely positioned for months in the womb in constant contact with the mother and her familiar rhythms. Such newborns will experience problems with latching and in establishing good relationship with the mother.⁷

From the above mentioned literature, it is evident that a period of close contact soon after the delivery is essential for both the mother and the newborn to enhance the innate behaviors. But the present hospital routine disrupts early mother infant contact leading to distress for both the mother and the newborn. In the present context, few studies addressed regarding the need of importance of early initiation of skin to skin contact. So the investigator felt the need to conduct research on effectiveness of early initiation of skin to skin contact in improving the maternal neonatal bonding and breast feeding status.

OBJECTIVES:

· Find the effectiveness of early initiation of skin to skin contact on maternal neonatal bonding among primiparous women.

· Find the effectiveness of early initiation of skin to skin contact on breast feeding status among primiparous women

· Find the association between maternal neonatal bonding with selected socio demographic variables

· Find the association between breast feeding statuswith selected socio demographic variables.

Hypothesis:

All hypotheses were tested at 0.05 level of significance

H₁: There will be significant difference in maternal neonatal bonding between experimental and control group.

H₂: There will be significant difference in breast feeding status between experimental and control group.

Conceptual framework:

The framework for the study was based on Ramona T Mercer ‘Maternal role attainment’ theory.⁸

RESEARCH METHODOLOGY:

Research approach:

Quantitative approach was adopted in this study.

Research design:

The research design selected for the study was a quasi experimentalpost test only control group design.

Research setting:

Research settings of the study were labor rooms and postnatal wards of Aswini and Valluvanad hospitals, Palakkad district, Kerala.

Research variables:

Independent variable - Early initiation of skin to skin contact,

Dependent variable- Maternal neonatal bonding, Breast feeding status.

Population:

The population of the study included all primiparous women and their newborns admitted to selected hospital of Palakkad district.

Sample and sample size:

A dyad sample of 60 primiparous women with their newborns who met the inclusion criteria were selected.

Experimental group:

Early initiation of skin to skin contact for 30 primiparous women and their newborns seven to ten minutes post delivery.

Control group:

30 primiparous women with their newborns provided with routine care.

Sampling technique:

Purposive sampling technique was employed

Development and description of the tool:

In this study the following data collection instruments were developed in order to obtain the data.

1. Socio demographic data:

2. Maternal neonatal bonding checklist:

This instrument was developed to quantify maternal neonatal bonding behaviours. The instrument is an observation checklist which consists of nonverbal behaviors, verbal behaviors, feeding behaviors and care taking behaviors. It consist of a total of 24 items. Each item in the checklist if present during the observation will be given one mark and if not present no mark will be given. Maximum score of every single observation is 24.

3. Infant breast feeding assessment tool:

This is a standardized instrument developed by Ms. Matthews to assess the breast feeding status. It consists of four items such as readiness to feed, rooting, fixing and sucking pattern with a score ranging from three to zero. Maximum score of single observation is twelve.

Content validity:

To ensure the content validity, the instruments along with the blue print, objectives and criteria checklist for content validity were submitted to seven experts in the field of Obstetric and Gynecological nursing, Child health nursing, Neonatology and Obstetrics for their opinion and suggestions.

Reliability:

Inter rater reliability method was used for testing the reliability of maternal neonatal bonding checklist and infant breast feeding assessment tool. The reliability coefficient for maternal neonatal bonding checklist was r=0.92 and for the infant breast feeding assessment tool was r=0.995.

Method of data collection:

The steps involved in data collection procedure were:

· Administrative permission to conduct the research study was taken from the Dean, Manipal College of Nursing, Manipal University, Manipal.

· Administrative permission was taken from the directors of Aswini and Valluvanad hospitals to conduct the research study.

· Permission obtained from unit heads of Obstetrics of Aswini and Valluvanad hospitals.

· Institutional ethical clearance for the study obtained from Aswini and Valluvanad hospitals, Ottapalam Palakkad district, Kerala.

· Informed consent was obtained from the primiparous women.

· The study sample consisted of experimental and control group. Early skin to skin contact was initiated for thirty primiparous women and their newborns in the experimental group within seven to ten minutes post-delivery, which was provided for a period oftwenty minutes whereas thirty primiparous women and newborns in the control group were provided with routine care. Initiation of breast feeding was done in both the groups as per hospital protocol within thirty minutes post-delivery. Posttest observations were done when the primiparous woman breast fed the newborn. First three observations were made during the first breast feeding. These observations were done for a period of two minutes followed by three minutes gap in a total duration of fifteen minutes. The investigator observed for the fourth time four hours post-delivery, whereas the fifth and sixth observations were done on first and second postnatal day. Breast feeding status was assessed only on second postnatal day.

RESULTS AND DISCUSSION:

Sample characteristics:

Primiparous woman’s characteristics:

· Majority of the primiparous women (53.3%) in the control group were in the age group of 21-25years, but the experimental group had equal distribution of women (40%) each in the age group of 16-20 years and 21-25 years.

· Majority of the primiparous women (53.3%) belonged to the joint family in the experimental group whereas in the control group majority (73.3%) of them belonged to the extended family.

· All the primiparous women in both the experimental and control group had planned pregnancy, had registered pregnancies and had regular antenatal visits.

· Majority of the women had not undergone infertility treatment in both experimental (73.3%) and control (96.7%) groups.

Newborn’s characteristics:

· There were equal numbers of female and male newborns in the experimental group (50%) where as in the control group majority (66.7%) of the newborns was males.

· Apgar scores for all newborns in both experimental and control were within normal range of 8-10.

· The birth weight of the newborns in experimental and control group were 2.938± 0.364 and 2.928± 0.330 respectively.

· Majority of the newborns were of 39 weeks of gestation in both experimental (53.3%) and control group (53.3%).

Effectiveness of early initiation of skin to skin contact on maternal neonatal bonding:

For all the six observation maternal neonatal bonding score were consistently high in experimental group compared to that of control group. Mann Whitney U test was used for finding the effectiveness of early initiation of skin to skin contact on maternal neonatal bonding. The obtained p value of cumulative maternal neonatal bonding (total of all six observations) (Z= 5.62, p= 0.001) shows a significant difference in maternal neonatal bonding between experimental and control group.

Figure: 1. Effectiveness of early initiation of skin to skin contact on maternal neonatal bonding

Figure 2: Bar diagram showing the cumulative maternal neonatal bonding scores in both experimental and control group.

Effectiveness of early initiation of skin to skin contact on breast feeding status:

Mann Whitney U test was used for finding the effectiveness of early initiation of skin to skin contact on breast feeding status. The p value of breast feeding status (Z= 0.763, p=0.446) shows that there is no significant difference in the breast feeding status between experimental and control group.

Association between maternal neonatal bonding and selected variables:

The p values of association between maternal neonatal bonding and selected variables, infertility treatment and type of family were significant at 0.05 level of significance, it is inferred that maternal neonatal bonding has a significant association with the variables, infertility treatment and type of family.

Association between breast feeding status and selected variables:

There was no significant association between breast feeding status with gender, birth weight and gestational age of the newborn.

OTHER FINDINGS:

It was observed during the conduct of the study that during episiotomy suturing the primiparous woman who had early initiation of skin to skin contact expressed more comfort and less pain during suturing compared to mothers who got routine hospital care. Newborns of the primiparous women who initiated early skin to skin contact post-delivery established rooting and sucking reflex immediately after the initiation of skin to skin contact.

DISCUSSION:

The findings of the present study indicate that there is a significant difference in maternal neonatal bonding between experimental and control group (p=0.001), which concludes that early initiation of skin to skin contact is effective in improving maternal neonatal bonding in primiparous women A similar study on early contact, social support and mother infant bonding showed that mothers who received early contact ( skin to skin contact for one hour) exhibited more significant affectionate behavior(p<0.005) than those who were given routine care. The study also revealed that skin to skin contact is equally effective in both primiparous and multiparous women. These study findings are consistent to the present study findings⁹. A randomized control trial on effectiveness of early contact on maternal attachment among 40 postnatal mothers revealed that the group who experienced early mother infant contact showed higher degrees of bonding and attachment (p<.01) than the group experienced the first contact after discharge from the hospital.¹⁰The findings of the above mentioned study are in line with the findings of the present study.

CONCLUSION:

The present study concluded that early initiation of skin to skin contact is an effective means of improving the maternal neonatal bonding. Early initiation of skin to skin contact is a feasible and effective method that could be practiced in any clinical setting without any difficulty. Nurses who are the primary health care providers play an important role in promoting early mother infant bonding in the immediate post-delivery or post-partum period by early initiation of skin to skin contact. The mothers should be advised about the benefits and importance of early initiation of skin to skin contact and should be encouraged in all clinical setting.

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Received on 24.07.2018 Modified on 20.08.2018

Asian J. Nursing Education and Research. 2018; 8(4):484-488.

DOI: 10.5958/2349-2996.2018.00099.X