Breastfeeding Initiation and Birth Setting Practices: A Review of the Literature

Della A. Forster, RN, RM, PhD; Helen L. McLachlan, RN, RM, PhD


J Midwifery Womens Health. 2007;52(3):273-280. 

In This Article

Third Stage and Immediate Postpartum

Separation of babies from their mothers for the completion of routine tasks, such as the administration of vitamin K, bathing, temperature stabilization, and eye prophylaxis, is common practice in many hospitals.[12] Separation of mother and baby should not be routine practice.

Continuous Skin-to-Skin Contact

Several studies have demonstrated the benefits of uninterrupted skin-to-skin contact between mother and baby for the first hour after birth.[33,52] Righard and Alade[33] observed 72 mother-newborn pairs immediately after birth. In one group (n = 34), the newborn was placed on the mother's abdomen but removed after about 20 minutes. In the skin-to-skin group (n = 38), contact between the infant and mother was uninterrupted for at least 1 hour after birth. Newborns in the skin-to-skin group were sucking at the breast by a mean of 49 minutes postpartum, having spontaneously made their way to their mother's breast.[33] Most healthy newborn infants placed between their mother's breasts[52] or on the abdomen[33] are able to locate the nipple without assistance and spontaneously attach and suck. Allowing this to occur is likely to optimize the position of the baby's tongue when latching on.[53] Even a brief separation of mother and infant may impact the success of this process, and therefore, the success of the first breastfeed.[33] Newborn infants appear to be able to identify their mother's breast by smell,[52,54] suggesting that unnecessary routine washing/cleaning of the breast may interfere with spontaneous breastfeeding initiation. Skin-to-skin contact immediately postpartum for an hour[55] or up to 2 hours enhances the ability of infants to maintain their temperature[56] refuting the belief of many care providers that skin-to-skin contact may cause a low temperature in newborns.

Early skin-to-skin contact is also likely to enhance breastfeeding duration, although the evidence has been inconsistent. A Cochrane review including 17 studies (N = 806 mother-baby pairs) assessed early skin-to-skin contact, although many of the included studies were of poor methodological quality. Early skin-to-skin contact had a positive association with babies being breastfed at 1 and 3 months postpartum (8 trials; 329 participants, OR, 2.15; 95% CI, 1.10-4.22), and with mean breastfeeding duration (6 trials; 266 participants, weighted mean difference 41.99 days; 95% CI, 13.97-70.00).[57] The largest trial to date (N = 204 mother-newborn pairs) showed no difference in breastfeeding outcomes when the group randomized to skin-to-skin care were compared to the group randomized to routine care[55]; however, the trial was powered to detect a 15% difference in groups, which may have been unrealistic. Additionally, it is important to note that mothers in the skin-to-skin group were significantly more satisfied.[55]

Women should be encouraged to have uninterrupted contact with their infant during the first hour after birth. There is no evidence to the contrary, and it is likely to have a range of benefits. There is no evidence about what specific breastfeeding position is optimal in the birth room, so mothers could be encouraged to adopt comfortable positions.

Time to First Feed

There is an association between the timing of the first breastfeed and the duration of breastfeeding, with earlier breastfeeding initiation[58] and/or mother-baby contact[59] associated with longer duration of breastfeeding, or decreased odds of very early cessation of breastfeeding.[60] Only one study was identified that found no association between infant to breast contact within 30 minutes of birth and breastfeeding duration: a prospective cohort study by Scott et al.[7] (N = 1059 women) in Australia. Step four of the Ten Steps suggests that care providers should help mothers initiate breastfeeding within half an hour of birth, and a systematic review of breastfeeding initiation, which included 59 studies, found that hospital initiatives that promote early mother-infant contact increase breastfeeding initiation.[22] Immediate and prolonged mother-infant skin-to-skin contact where the infant has the opportunity to initiate breastfeeding should be the routine practice in birth environments.


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