Women and Birth 27 (2014) 37–40

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Women and Birth

journal homepage: www.elsevier.com/locate/wombi

Effect of immediate and continuous mother–infant skin-to-skin

contact on breastfeeding self-efficacy of primiparous women:
A randomised control trial
Karimi Aghdas a, Khadivzadeh Talat b, Bagheri Sepideh c,*
a
Student Research Committee, Department of Midwifery and Reproductive Health, Nursing and Midwifery School, Mashhad University of Medical Science,
Mashhad, Iran
b
School of Nursing and Midwifery and Women Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
c
School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

A R T I C L E I N F O A B S T R A C T

Article history: Objective: To evaluate the effect of mother–infant immediate skin-to-skin contact on primiparous
Received 3 July 2013 mother’s breastfeeding self-efficacy.
Received in revised form 25 September 2013 Study design: A randomised control trial.
Accepted 26 September 2013
Settings: The study was conducted in Omolbanin obstetrics hospital (large tertiary hospital), Mashhad,
Iran.
Keywords: Participants: 114 18–35 year-old primiparous, Iranian, healthy and full term mothers who anticipated
Skin-to-skin contact
normal vaginal delivery and intended to breastfeed their babies.
Routine care
Breastfeeding self-efficacy
Intervention: Skin-to-skin contact immediately after birth and then controlling breastfeeding self-
BSES efficacy at 28 days postpartum.
Breast feeding initiation Main outcome measure: Maternal breastfeeding self-efficacy at 28 days postpartum and success in first
breastfeeding and mean time of first breastfeeding initiation.
Results: A total of 92 mother–infant dyads (47 dyads in skin-to-skin care skin-to-skin contact group and
45 dyads in routine care group) were monitored and analysed. In skin-to-skin contact group,
breastfeeding self-efficacy was 53.42  8.57 SD as compared to 49.85  5.50 SD in routine care group
which is significantly higher in skin-to-skin contact group (p = 0.0003).
Successful breastfeeding initiation rate was 56.6% in skin-to-skin contact group as compared to 35.6%
in routine care group (p = 0.02).
Time to initiate first feed was 21.98  9.10 SD min in SSC group vs. 66.55  20.76 min in routine care
group (p < 0.001).
Conclusion: Mother–infant immediate skin-to-skin contact is an easy and available method of enhancing
maternal breastfeeding self-efficacy. High breastfeeding self-efficacy increases exclusive breastfeeding
duration.
ß 2013 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International
Books Australia Pty Ltd). All rights reserved.

1. Introduction
Breast milk is the optimal nutritional source for infants1–4 and it
provides species and age specific nutrients and the best nutritional
balance for them.1–4 Despite breast milk’s great benefits for the
health of infants, breastfeeding rates are declining all around the
world,5,6 as well as in our country Iran.7 This decrease in exclusive
* Corresponding author at: Dr Sheikh Children’s Hospital, Mashhad, Iran.
Tel.: +98 915525545.
E-mail address: bagheris@mums.sc.ir (B. Sepideh).
breastfeeding rate is partly due to separating mother and the infant
after birth.8
The first 2 h after birth is called the sensitive period9 and this is
the best time for mother to initiate breastfeeding the infant.10 In
this period, maternal–infant separation, even for a short time, can
decrease the neonate’s ability to initiate breastfeeding and may
also lead to a reduction in maternal confidence and self-efficacy.11–
13
Immediate mother–infant skin-to-skin contact (SSC) after birth
has been proven most effective in successful initiation and
continuation of breastfeeding.14
Skin-to-skin contact is achieved by holding the naked baby
against the mother’s chest between her breasts.15 The effect of

1871-5192/$ – see front matter ß 2013 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
http://dx.doi.org/10.1016/j.wombi.2013.09.004
38 K. Aghdas et al. / Women and Birth 27 (2014) 37–40
mother–infant skin-to-skin contact on breastfeeding behaviours of
infants is well known.16–18
Importance of maternal self-efficacy on breastfeeding initiation
and continuation has been demonstrated consistently.14,19,20
Breastfeeding self-efficacy refers to the confidence of a woman
in her ability to breast feed her baby.21,22 This study was conducted
to assess the effect of early mother infant skin-to-skin contact on
maternal breastfeeding self-efficacy.
2. Methods
2.1. Setting
A randomised control trial was conducted from 1st April 2012
to 31st July 2012 in Omolbanin obstetrics hospital (large tertiary
hospital), Mashhad, Iran. This hospital is affiliated with the faculty
of medicine of Mashhad University of Medical Sciences.
2.2. Participants
The study population consisted of 114 primiparous, Iranian,
healthy, full term mothers between 18 and 35 years of age who
anticipated normal vaginal delivery and intended to breastfeed
their babies.
Mother–infant pairs were considered ineligible and were not
enrolled in this study if they had any of the conditions mentioned
in Table 1.
The study was approved by the ethical committee of Mashhad
University of Medical Sciences prior to performance and eligible
mothers signed informed consent.
2.3. Enrollment and intervention
Mother–infant pairs were screened for eligibility by two
research assistants. Eligible mother–infant pairs were then
randomly assigned to either of the two groups, skin-to-skin
contact SSC group (n = 57) and routine care group (n = 57). They
were allocated in a 1:1 ratio to each group. One research assistant
accompanied mothers in both groups till the end of the second
hour after labour. In SSC group infants were placed naked against
their mothers’ skin in prone position. Infants’ heads were covered
with dry caps and warm blankets were placed on their backs.
Mothers were helped to keep this position for at least 2 h. Routine
hospital cares such as weighing and vitamin K injection were
postponed for 2 h in this group. In routine care (RC) group, infants
were kept under a radiant heater immediately after cutting their
cords. They received vitamin K injection and their weight, length
and head circumference measurements were recorded and then
they were wrapped in pre-heated blankets and were transferred to
their mothers.
Table 1
Maternal exclusions and neonatal exclusions.
Maternal exclusions Neonatal exclusions
Medical complications (diabetes, Gestation < 37 weeks
hypertension, psychiatric problems, etc.)
Severe postpartum haemorrhage Weight < 2500 or >4000 g
Multiple pregnancy Apgar score < 7
Caesarean section Major congenital anomalies
Unwanted pregnancy Floppiness
Anatomical breast defects, or Severe medical problems
history of breast surgery
Use of drugs not compatible Admission to a neonatal unit
with breastfeeding
Educations in medical sciences,
psychology or counselling
2.4. Randomisation
The randomisation sequence was generated by the statistical
adviser of the research programme using computerised research
randomiser. The sequence was concealed from the research
assistants in sequentially numbered sealed opaque envelop. The
envelops were opened after the mothers signed the consent forms.
All follow-up data were collected by 2 research assistants who
were blind to group assignment (SSC and control group) at day 28,
but they were aware of the purpose of the study.
2.5. Data collection
The research questionnaire was developed by the researchers
and consisted of 2 parts: Part 1: Maternal characteristics and part
2: Infant’s data.
Infant Breast Feeding Assessment tool (IBFAT) was used to
measure ‘‘success in first breastfeeding’’. The IBFAT evaluates
four parameters of infant suckling competence including
readiness to feed, rooting reflex, latch-on, and suckling pattern.
The infant can receive a score of 0–3 on each item for a maximum
total score of 12. Achieving scores between 10 and 12 from IBFAT
tool showed success and scores less than 10 showed failure in
first breast-feeding. IBFAT is a reliable tool for assessing infant
success in first breastfeeding which has been used in several
studies.13,23,24 Reliability of this tool was assessed by observing
20 cases of breastfeeding in a pilot study, in which Kapa
coefficient was 0.92.
At day 28 postpartum, the assigned research assistant ques-
tioned all participants through phone to determine maternal
breastfeeding self-efficacy using breastfeeding self-efficacy scale
(BSES)25 which is a 33 item self report instrument to measure
maternal breastfeeding confidence. As recommended by Ban-
dura26 all items are presented positively and higher scores indicate
higher levels of confidence. In this study we used the Persian
version of BSES. In a previous study, Persian version of BSES had
high internal consistency reliability (a = 0.82).27 In the current
study the scale was used at day 28 postpartum and it had also high
internal consistency reliability (cronbach’s alpha coefficient was
0.9). All items are anchored with a 6-point Likert-type scale where
1 = strongly disagree and 6 = strongly agree.
2.6. Outcome measure
The primary outcome was maternal breastfeeding self-efficacy
at 28 days postpartum. The secondary study outcomes were
success in first breastfeeding and mean time of first breastfeeding
initiation.
2.7. Statistical analysis
Data were analysed using SPSS software, version 14. Data were
presented using descriptive statistics including means, standard
deviations, and proportions. Student’s t-test was used for
quantitative data and chi square for qualitative data.
Mann–Whitney test was used for parameters with non normal
distributions. For all tests level of significance in terms of p value
was 0.05.
Fig. 1 shows the methodology flowchart used for carrying out
this study.
3. Results
114 eligible mothers according to inclusion and exclusion
criteria were enrolled in this research programme. At the end of the
study 92 mother–infant dyads were assessed.
 K. Aghdas et al. / Women and Birth 27 (2014) 37–40 39

Fig. 1. Flowchart representing the methodology used for carrying this study.

Demographic and clinical characteristics of the participants are
shown in Table 2. There is no significant inter-group baseline
difference between the 2 study groups.
Mean BSES score was 53.42  8.57 SD in SSC group and
49.85  5.50 in RC group and the student’s t-test shows a significant
difference between them (p = 0.0008).
Success in first breastfeeding in SSC group was 56.6% vs. 35.6%
in RC group (p = 0.02).
Mean time of first breastfeeding initiation was 21.98  9.10 SD min
in SSC group and 66.55  20.76 SD min in RC group (p < 0.0001).
This study provided additional results regarding how confident
mothers are breastfeeding their infants. The two groups were

Table 2
Demographic and clinical characteristics of the study groups.

Variable Group

SSC (n = 47) Routine care (n = 45) p-Value

Maternal
Age (mean  SD) 22.02  2.84 21.62  2.73 0.49
Education (years) (mean  SD) 9.8  5.63 9.97  6.1 0.89
Spouse education (years) (mean  SD) 8.02  5.13 8.7  5.52 0.27
Stage I labour (min) (mean  SD) 267.68  85.65 244.75  78.43 0.18
Stage II labour (min) (mean  SD) 37.28  17.92 35.95  19.14 0.73
Infant
Sex
Female 27(n), 57.4 (%) 25(n), 55.6 (%) 0.85
Male 20(n), 42.6 (%) 20(n), 44.4 (%)
Birth weight (g) 3121.73  509.55 3237.55  347.34 0.2
Gestational age (weeks) 38.29  1.24 38.39  1.19 0.94
40 K. Aghdas et al. / Women and Birth 27 (2014) 37–40
Table 3
BSES Statements in mothers of both groups.
Statement SSC Routine care
(strongly agree) (strongly agree)
I have the necessary skills to breastfeed 51.06% 20%
I know how to breast feed 57.44% 17.7%
I won’t need help to breastfeed 61.70% 31.11%
Breastfeeding is easy 57.44% 28.88%
I am confident I can breastfeed 68.05% 15.55%
I know I will have enough 70.21% 40%
milk for the baby
asked to rate BSES statements provided by research assistants
during the phone call. Table 3 summarises the percentages of the
participating mothers who strongly agreed with statements within
both groups.
4. Discussion
The results of this study show that immediate mother–infant
skin-to-skin contact leads to higher breastfeeding self-efficacy in
mothers. During skin-to-skin contact, mothers provide tactile and
verbal stimulation to their newborn infants and this practice
improves breastfeeding behaviours of healthy full term
infants.16,17,28 This method of care is also associated with greater
levels of maternal satisfaction and mothers gain higher confidence
in their ability to breastfeed and care for their neonates.31–33
Maternal breastfeeding self-efficacy is one of the most
important factors in maintaining and continuation of brestfeed-
ing.14,19 Studies have shown significant positive effects of
immediate and continuous mother–infant skin-to-skin contact
on exclusive breastfeeding.28 In this study, early skin-to-skin
contact increased breastfeeding self-efficacy score which is
comparable to other studies.29,30
This study also showed that SSC has a great positive effect on
success of first breastfeed (56.6% vs. 35.6%) which is almost
comparable to the results of a study by Moore et al.12 and another
trial by Walters et al.29
Time to initiate first feed was also shorter in SSC group which is
similar to a study by Iqbal et al.31 but in Moors study this time was
equal in both groups.
This method of care is also associated with greater levels of
maternal satisfaction and mothers gain greater confidence in their
ability to breastfeed and care for their neonates.31–33
Our follow up at 1 month post birth is possibly short and
prolonged follow ups may be needed. Future research is mandated
to evaluate the effects of this policy on breastfeeding rates and
exclusivity in longer follow up periods.
5. Conclusion
Our study has shown that immediate mother–infant skin-to-
skin contact is an easy, inexpensive and non-invasive method of
increasing maternal breastfeeding self-efficacy and confidence.
Improved breastfeeding self-efficacy will result in exclusive
breastfeeding and can prevent premature discontinuation of
breastfeeding. This shows that hospital practices can have an
important influence on breastfeeding self-efficacy. Early separa-
tion of mother and infants should strongly be discouraged.
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