Influence of Skin-to-Skin Contact and Rooming-In on Early Mother

Abstract

The objective of this research was to study influence of birth routines on mother–infant interaction at Day 4. The present research is part of a longitudinal study where mother–infant pairs were randomized by infant location and apparel. We intended to assess mother–infant interaction from videos filmed at Day 4. A protocol for the assessment/coding of the affective quality of maternal behaviors indicative of early mother–infant interaction was developed and interculturally validated. Results were compared with birth randomization, as to explain impact of birth practices. Findings indicate that separation and swaddling at birth interfered with mother–infant interaction during a breastfeeding session at Day 4; these mothers significantly demonstrated more roughness in their behaviors with their infants at Day 4. Results also show evidences of a sensitive period for separation after birth. Implications are to encourage immediate and uninterrupted skin-to-skin contact at birth, and rooming-in during postpartum, as recommended in World Health Organization/UNICEF Ten Steps for Successful Breastfeeding.

Keywords

breastfeeding skin-to-skin mother–infant interaction rooming-in early sensitive period randomized controlled trial video analysis assessment of early mother–infant interaction Baby-Friendly Hospital Initiative BFHI

Introduction

Mother–infant interaction is a gradual mutual adaptation, following repeated intimate dialogues. However, little is known about the influence of birth routines on this process. Als (1975) believes that breastfeeding yields an “opportunity for synchrony” in the mother–infant relationship because of repeated intimate contacts and involvement required from the mother. Widström et al. (1990) found that newborn’s behavior influenced in specific ways how the mother interacted with her infant during the days after birth. When the infant suckled or touched the mother’s breast soon after birth, the mother spent more time with her baby and talked more to the infant in the maternity ward. Similarly, Lavelli and Poli (1998) compared early mother–infant interaction during breastfeeding and bottle-feeding. They showed that breastfeeding mothers experienced a better opportunity to communicate with their newborn; their interactions at Day 3 were based on mutual touch and gaze, and mothers caressed their baby more often. However, the authors did not specifically correlate their findings with events from the birth period, for example, with skin-to-skin contact and nonseparation, which could prove important for early attachment.

Feldman, Eidelman, Sirota, and Weller (2002) showed that kangaroo care has a significant impact on the interaction between the mother and her premature infant. They analyzed 146 videos with the Mother–Newborn Coding System developed by one of the authors (Feldman, 1998), focused on maternal touch, gaze, talk, adaptation, and intrusiveness, along with the infant state. Their results show that mothers of infants in the kangaroo care group were more positive in their affect, touch, and adaptation to infant cues at 37 weeks’ gestational age, than those whose babies received standard incubator care. The authors concluded that kangaroo care has a direct impact on maternal interactive behavior by providing proximity. We would posit that this is probably the same with term newborns.

In fact, Bystrova (2008) explored the impact of practices at birth related to separation (rooming-in or nursery) and to type of infant’s apparel (skin-to-skin, clothes, swaddling). The results indicated the existence of a sensitive period near birth for the early development of mother–infant interaction, such as some authors have previously suggested (Hales, Lozoff, Sosa, & Kennel, 1977; Kennel, Trause, & Klaus, 1975; Klaus, Jerauld, Kreger, McAlpine, Steffa, & Kennel, 1972; Klaus & Kennel, 1976). Furthermore, World Health Organization (WHO)/UNICEF advocates practices based on these principles in the Baby-Friendly Hospital Initiative (WHO, Division of Child Health and Development, 1998; WHO/UNICEF, 2009). The Ten Steps for Successful Breastfeeding involve respect of perinatal practices such as immediate placement of the baby in skin-to-skin contact with the mother at birth, without interruptions for at least 1 hour, and then, keeping mother and baby together during their postpartum period, unless it is medically justified to separate them (for more details, see Breastfeeding Committee for Canada, 2011).

In Russia and many countries of the former USSR however, tight swaddling is still widely used at birth and also the baby is separated in a nursery. Infants are brought to their mother’s room on strict schedule to be breastfed. Fathers or family members do not come to visit the maternity, first meeting the baby at discharge after 6 or 7 days. Swaddling as in Russian cultural traditions requires the tight wrapping of the baby’s body in cotton blankets, which immobilizes the infant (Figure 1). The swaddled baby has difficulty to move the head and to exhibit early signs of wakefulness or hunger. Babies remain swaddled while in the nursery, in individual cots, and also if they are rooming-in with their mother (Figure 2).

The actual problem is that we do not have evidences that birth routines, such as skin-to-skin contact and nonseparation at birth, influence mother–infant interaction within the early days after birth, moments where the attachment process is beginning. This study is part of a longitudinal research project exploring the impact of perinatal practices in a Russian maternity home on various physiological and psychosocial variables, one of which was mother–infant early interaction. This article reports one part of the study, the aim of which was to uncover maternal behaviors indicative of early mother–infant interaction, by analyzing videos filmed on Day 4 during a breastfeeding period. Those data would then serve to examine whether skin-to-skin contact, baby’s apparel, and separation affected the mother–infant interaction at Day 4, during the breastfeeding episode that was videotaped (see Table 1 for specific objectives).

Table 1.

Aims of the Study.

The aim of the present study was to explore maternal behaviors during a breastfeeding session 4 days after childbirth and the influence of perinatal care routines such as skin-to-skin contact, baby’s apparel, and separation on mother–infant interaction. More specifically, the intent was to examine whether

1. Skin-to-skin contact at birth influences the mother–infant interaction at Day 4

2. Separation at birth influences the mother–infant interaction at Day 4

3. Swaddling influences the mother–infant interaction at Day 4, as compared with clothing

4. Impact of a 2-hour separation at birth

5. There are indications of a sensitive 2-hour period at birth

This study is part of a longitudinal study examining the influence of perinatal practices on physiological and psychosocial variables and summarized as

Inclusion criteria based on normalcy

• Women who were in good health and experienced a totally normal and uncomplicated pregnancy

• Gave birth to a healthy, full-term vaginally delivered singleton baby, in occipital presentation, without use of oxytocin, analgesia, or anesthesia, and with an APGAR of at least 8 at 5 minutes

• Mothers intended to breastfeed and agreed to be randomized into one of eight groups

• All the women signed an informed consent for their participation in the study

Exclusion criteria

Three hundred and eighty-six eligible mothers were approached during the 4 years of data collection because they met inclusion criteria. See flow diagram in Figure 3

Sample: Consisted of 176 women strictly fulfilling the inclusion criteria

Randomization

• Mothers were randomly assigned to one of the eight groups (see Table 2) as to randomize by skin-to-skin or clothes or swaddling and as per nonseparation, separation, or separation/reunion 2 hours after birth

• Group assignments were placed in opaque sealed envelopes numbered in the order they should be used (1-88 multipara and 1-88 for primipara), so blind to all involved in the study

• All infants were subjected to mandatory Russian procedures for the first 20 to 25 minutes before being randomized in one of the eight groups (immediate cord clamping, placement on examination table to be washed, dried, weighed, etc.)

Description of the detailed procedures for the overall longitudinal research and data collected has been reported elsewhere (Bystrova, 2008)

The present study procedures are explained in the present text

Material and Method

The present article will focus on the analysis of 151 videos of mother–infant dyads filmed during a breastfeeding period, at postpartum Day 4, in the mothers’ rooms. The videos are part of data collection of a longitudinal study (Bystrova, 2008; Bystrova et al., 2009) in one maternity home in St. Petersburg, where 2,200 births occur annually. The recruitment being centered on such strict criteria of normalcy as described in Figure 3, it lasted 4 years, during which only 386 women could be approached to be part of the study. Immediately after birth, 176 were eligible and volunteered to be blindly randomized into one of eight groups (Table 2). Summary of the research procedures for the longitudinal study can be found in Figure 3 and those for the present part of the research follow in this text.

Table 2.

Randomization Into Eight Groups in the Longitudinal Study.

			Delivery ward		Maternity ward
Main groups	Group numbers	Videos (Day 4, n = 151)	Location	Apparel	Location	Apparel
I: “Skin-to-skin” group	1	18	Skin-to-skin	—	Rooming-in	Swaddling
I: “Skin-to-skin” group	2	15	Skin-to-skin	—	Rooming-in	Clothes
II: “Mother’s arms” group	3	21	Mother’s arms	Swaddling	Rooming-in	Swaddling
II: “Mother’s arms” group	4	20	Mother’s arms	Clothes	Rooming-in	Clothes
III: “Nursery” group	5	19	Nursery	Swaddling	Nursery	Swaddling
III: “Nursery” group	6	19	Nursery	Clothes	Nursery	Clothes
IV: “Reunion” group”	7	18	Nursery	Swaddling	Rooming-in	Swaddling
IV: “Reunion” group”	8	21	Nursery	Clothes	Rooming-in	Clothes

Note: Numbers are for Day 4 videos only.

Source: Adapted from Bystrova (2008) with permission.

Videos were available only for 151 mother–infant dyads (out of the 176 from birth randomization) as 4 mothers withdrew from the study after birth, 19 deviated from randomization in the postpartum period, and 2 videos were not technically suitable for analysis. Each of the videos lasted from 25 to 45 minutes, with the camera focused on the mother and baby without interaction with the person behind the camera. They were analyzed for their visual content and maternal tone of voice, and the results were compared with events related to the birth randomization. Coders were blind to the birth randomization. No tool assessing the quality of mother–infant interaction from a visual content was found, so an observation protocol for coding and analyzing the videos was developed and interculturally validated. The intent was to uncover the maternal behaviors from the visual and tone of voice aspects of the videos and not from the analysis of the dialogue in Russian between the mother and her baby.

Ethical approval for the overall longitudinal research was granted by the Ethics Committee of the Karolinska Institutet, Stockholm and the Health Care Division of the Mayor-Council of St. Petersburg. When a researcher from Canada (LD) joined the team after data collection, an additional approval from the Research Ethics Committee at the Université du Québec en Outaouais (Western Québec) was obtained for the analyses of the videos filmed on Day 4 and subject of the present article.

The Instrument

In the present study, an assessment tool was developed and validated to evaluate mother–infant interaction (Table 3). Items derive from review of the literature and theory, coupled with the main researcher’s experience. Seven items are short statements of the quality of mother’s behavior assessed on a scale from 1 to 5 (from roughest to most gentle behavior); two items are on a 3-point scale, and three items are to be answered “yes or no” according to occurrence or nonoccurrence of the behavior. Added to this are two moments to assess baby’s state of wakefulness as per Brazelton (1984) and field notes from the observer. Number “9” is used to code nonobserved behaviors. Excerpts from the coding guide present an example of definition of the variables (Table 4).

Table 3.

Assessment Tool for the Observation of Mother/Infant Interaction (Dumas, Bystrova, & Widström, 2005).

Element of observation	Scale choices 5 to 1
Cass. Video #: _________________ Bb’s Clothes: _________ State of wakefulness as per Brazelton at the start of the video: _________
Respond to each statement as to qualify the predominant behavior observed.
Do this on a 1 to 5 scale: 1 being the lowest level (roughness), 5 being the highest level (softness)


1. Mother’s movements to the baby and with the baby	5	4	3	2	1
2. Mother’s attempts at latch	5	4	3	2	1	9
3. Mother’s voice	5	4	3	2	1
4. Mother’s patience	5	4	3	2	1
5. Mother’s stimulation	2	1
• Types of mother’s stimulation if yes	5	4	3	2	1
6. Stimulation of the baby by staff	2	1
• Types of staff’s stimulation if yes	5	4	3	2	1
• Mother takes staff as model	1	2
7. Mother’s pain at latching	1	2	9
8. General mother’s affective responsiveness to baby	5	4	3	2	1
9. Eye-to-eye contact	3	2	1	9
10. Attempts at eye contact	1	2	3	9
11. Movements of avoidance of baby	1	2
12. At least one effective breastfeeding sequence	1	2

State of wakefulness as per Brazelton during most of the sequence: _________

Field notes:

Table 4.

Definition of Some Variables: Excerpts From the Coding Guide Designed for the Assessment Tool for the Observation of Mother/Infant Interaction (Dumas et al., 2005).

Bb’s Clothes: baby’s apparel
Swaddled including head = swaddled on all body = head and hands restricted	Swaddled without head = swaddled body but head is free = tight bundling
Covered = baby enveloped in a cover = head free to move but hands restricted	Clothed = clothes = head and hands are free since not swaddled, not covered
Skin-to skin = unclothed baby is placed directly on mother’s skin

STATE OF WAKEFULNESS AS PER BRAZELTON (1984): deep sleep, light sleep, semi-alert, alert, crying

QUALITY OF PREDOMINANT BEHAVIOR ON A 5 ←--------→ 1 QUALITY SCALE (“9” is used when behavior nonobserved)
1. Mother’s movements to the baby and with the baby:
From 5: Soft, slow, gentle stroking on baby’s body
to 1: Dry, rough, on her body or on baby’s body
2. Mother’s attempts at latch:
From 5: Offering breast gently, softly readjusting her position or the baby’s position
to 1: Pushing breast into baby’s mouth, attempts to open baby’s mouth, pinches baby’s nose
5. Type of mother’s stimulation, if present:
From 5: Soft, tender stimulations
to 1: Roughness in mother’s stimulations
8. General mother’s affective responsiveness to baby:
From 5: Positive, calm, no attempt to have baby suck at all cost, or attempts are relaxed and positive, smiles at baby, touches baby, looks at baby
to 1: Negative, stressed, impatient attempt to have baby suck, doesn’t leave baby rest between sucking movements, when touches baby, doesn’t do it gently

7. Mother’s pain at latching:
Objective observation of mother’s pain in her face is or is not present (or cannot be observed)

Examples to assist in differentiating soft and rough behaviors:
Gentle or soft = light, kind, mild, tender movements or voice; light touch: no depression of the baby’s skin or light depression of the baby’s skin with mother’s fingers, “effleurage” or light brushing of the baby’s skin; movements and voice are not rough, not hard, not loud
Rough = hard, rude, abrupt, harsh, loud; hard touch: depression of the baby’s skin with mother’s fingers; pinching nose, neck, skin, cheeks; forcing mouth open; pushing breast into baby’s mouth; shaking baby

This instrument was developed for both research and clinical observations; it intends to systematically assess the affective quality of predominant behaviors indicative of early mother–infant interaction during a breastfeeding sequence. It is not focused on quantitative occurrences of any behavior, but more on the qualitative visual–auditory aspect of the variables. For those reasons, a short form was preferred with easy-to-code scaling system, not requiring intensive training for its use but only availability of a detailed coding guide.

This instrument was interculturally validated by expert panels for face and content validity (Lynn, 1986; Nieswiadomy, 2002; Nunnally, 1978; Roberts & Burke, 1989) and interobserver reliability (Castorr et al., 1990; Taylor, 1994; Tomalin, Oliver, Redfern, & Norman, 1993). Successive panels of seven perinatal experts from Sweden, Russia, Canada, and the United States contributed to the intercultural appraisal of content and discriminating ability of the instrument. The validation of the tool was challenging as words carry emotional value of images from the videos and all words are bound to culture. For example, Swedish, Russian, American, and French Canadian health professionals do not attribute the same meaning to the words “soft voice,” “rough behavior,” “patience of a mother towards her child’s state of alertness.” This is why the experts were very useful in enriching the coding guide accompanying the tool; this servers as an operation manual as suggested by Hulley et al. (2001). Successive expert panels lead to a content validity index of at least .86 for each of the 12 items (minimal agreement of 6/7 experts; Nieswiadomy, 2002; Roberts & Burke, 1989). Five randomly chosen videos were then assessed with five perinatal experts to obtain an interobserver’s reliability of at least .80 for each item (minimal agreement of 4/5 observers; Burns & Grove, 2001; Polit & Hungler, 1999). This is acceptable as 75% interjudge agreement is normally acceptable (Siegel & Castellan, 1988). No construct validity was attempted for this newly designed tool as we were trying to describe behaviors from videos that were already filmed and not to create a situation in order to validate an instrument. As explained by Polit and Hungler (1999), “the significance of construct validity is in its linkage with theory and theoretical conceptualisation” (p. 421), which was not the intent here.

Coding of all 151 videos was completed over a 2-month period by the main researcher and the author of this tool; this was an intensive coding period with only one coder, thus facilitating reliability (Polit, Gillespie, & Griffin, 2011). At that moment, she was blind to the birth randomization. Additionally, to ensure that reliability was maintained even more during the coding period, two other researchers from the panel independently coded randomly chosen videos, obtaining at least a minimal agreement of .80 with the main coder (Polit, 2010).

Statistical Considerations

Statistical analyses were performed on the 151 coded videos by SPSS 19.0. Afterward, statistical analyses were performed to compare what was seen in the videos with events that happened at birth and during the postpartum period. Pearson’s chi-square two-sided test was used, with an α = .05, since relationships were sought between ordinal variables, and groups were compared (Corty, 2007; LoBiondo-Wood & Haber, 2005). As no literature was available on this subject, a medium size effect was considered with an α = .05 and a statistical power at .80 (Beck, 1994). The required number of subjects was between 120 (2 degrees of freedom [df]) and 160 (6 df; Cohen, 1988). For this study, the original eight groups were merged and/or compared in different constellations to answer aims (see the second row in Table 5). The aims were considered with respect to all 14 variables from the assessment tool (see first column in Table 5).

Table 5.

Summary of Statistical Results When Comparing Data From Mother–Infant Interaction During a Breastfeeding Session at Day 4 With Events in the First 2 Hours After Birth^a.

Items Day 4 ↓ (see Table 3)
Comparisons →	Comparing skin-to-skin and mother’s arms at birth	Comparing skin-to-skin and separation	Comparing mother’s arms and separation	Comparing apparel (clothes, swaddling)	Comparing apparel when separated in first 2 hours	Comparing apparel in postpartum when not separated	Comparing skin-to-skin and separation in first 2 hours	Comparing separated and separated/reunited	Comparing mother’s arms and separation for 2 hours at birth
Groups involved → (see Figure 3)	(1 + 2) versus (3 + 4)	(1 + 2) versus (5 + 6)	(3 + 4) versus (5 + 6)	(1 + 3 + 5 + 7) versus (2 + 4 + 6 + 8)	(5 + 7) versus (6 + 8)	(1 + 3) versus (2 + 4)	(1 + 2) versus (7 + 8)	(5 + 6) versus (7 + 8)	(3 + 4) versus (7 + 8)
1. Mother’s movements	ns	ns	ns	ns	ns	ns	ns	ns	ns
2. Mother’s attempts at latch	ns	χ² = 9.281, 2 df, p = .010	χ² = 9.282, 2 df p = .010	ns	ns	ns	χ² = 8.622, 4 df, p = .013	ns	χ² = 6.484, 2 df, p = .039
5. Type of mother’s stimulation	ns	χ²= 4.059, 1 df, p = .044	ns	ns	ns	ns	ns	ns	ns
7. Mother’s pain at latching	ns	χ² = 4.402, 1 df, p = .036	ns	ns	ns	ns	χ² = 4.582, 1 df, p = .032	ns	ns
8. Mothers affective responsiveness	ns	ns	ns	ns	χ² = 6.918, 2 df, p = .031	ns	ns	ns	ns
Brazelton: Wakefulness at start	ns	ns	ns	ns	ns	ns	ns	ns	ns
Brazelton: Wakefulness most of the sequence	ns	ns	χ² = 11.328, 3 df, p = .010	χ² = 8.946, 3 df, p = .030	ns	χ² = 14.459, 3 df, p = .002	ns	ns	ns

See study groups in Table 2.

Results

In this randomized study, in principle, an analysis of the effect of one procedure (e.g., swaddling) is that all other procedures are balanced in the calculation (e.g., skin-to-skin for 2 hours, in mother’s arms for 2 hours, nursery during postpartum, rooming-in in postpartum). Results from the analyses of Day 4 videos compared with events from birth are summarized in Table 5. Results are presented for each aim of the present study (see Table 1) and according to study groups (see Table 2).

Skin-to-skin contact at birth influences the mother–infant interaction at Day-4—skin-to-skin groups (Groups 1 + 2) versus clothed groups (Groups 3 + 4). We did not find any significant difference between those groups during a breastfeeding session on Day 4.

We then tried to find out if separation from birth to Day 4 influences the mother–infant interaction at Day 4 during a breastfeeding session, by comparing extremes: skin-to-skin and rooming-in groups (Groups 1 + 2) versus mother–baby separated groups (Groups 5 + 6). Three variables were found statistically significant: attempts at latch (χ² = 9.281, p = .010, 2 df), stimulation by mother (χ² = 4.059, p = .044, 1 df), and pain at latching (χ² = 4.402, p = .036, 1 df). When babies were in the nursery, mothers were rougher (on the 1-5 scale) in their attempts at latching and stimulating their babies compared with mothers who had been skin-to-skin and not separated. Pain at latching was more frequent in mothers in the skin-to-skin group.

We wanted to see if proximity with the mother within the first 2 hours at birth was influencing the mother’s behavior with her baby 4 days later during a breastfeeding session, differently than skin-to-skin contact at birth. So we compared Groups (3 + 4) and (5 + 6), mother’s arms, and nursery groups. Two variables came out significant: attempts at latch (χ² = 9.282, p = .010, 2 df), and state of wakefulness during most of the sequence (χ² = 11.328, p = .010, 3 df). When babies have been in the nursery, mothers were rougher in trying to get their babies to latch. Babies showed a lack of wakefulness during most of the breastfeeding sequence.

We then compared groups to see if swaddling influenced mother–infant interaction during a breastfeeding session at Day 4; comparison was made between clothed babies (Groups 2 + 4 + 6 + 8) and swaddled babies (Groups 1 + 3 + 5 + 7). Wakefulness most of the sequence (χ² = 8.946, p = .030, 3 df) was significantly lower in the swaddled babies.

We then isolated dyads who were separated during the first 2 hours after birth to see if type of apparel made a difference, comparing swaddled babies (Groups 5 + 7) and clothed babies (Groups 6 + 8). There was a significant difference in the general affective response of mother to her baby (χ² = 6.918, p = .031, 2 df); mothers were rougher with their babies when they were swaddled. Furthermore, to isolate the specific effect of swaddling, we compared groups who were skin-to-skin or dressed, then rooming-in with their mothers while either swaddled (Groups 1 +3) or clothed (Groups 2 + 4). We found a significant difference in the variable wakefulness most of the sequence (χ² = 14.459, p = .002, 3 df) concerning the swaddled babies who were hard to wake up during most of the breastfeeding session.

We were interested in assessing the impact of a 2-hour separation at birth on mother–infant interaction at Day 4 during a breastfeeding session. We compared groups that experienced skin-to-skin contact and rooming-in (Groups 1 + 2) and groups that were separated from birth and then reunited 2 hours later (Groups 7 + 8). We found a significant difference on mother’s attempts at latch (χ² = 8.622, p = .013, 4 df). Mothers were rougher if they had been separated from their babies at birth without experiencing skin-to-skin contact. We also found a significant difference on the variable pain at latching (χ² = 4.582, p = .032, 1 df); mothers who were not separated were more sensitive to latch at Day 4. Trying to find out if the first 2-hour separation made a difference on mother–infant interaction during a breastfeeding session 4 days later, we compared groups that were always in the nursery from birth, coming to their mothers at strict schedules to breastfeed (Groups 5 + 6) and those who were initially separated for the first 2 hours and then reunited in rooming-in with their mothers (Groups 7 + 8). We did not find any statistical difference between the two groups.

Our last goal was to see if results show some indications of a 2-hour sensitive period at birth. In trying to find this out, we specifically studied groups: skin-to-skin against reunion (Groups 1 + 2) versus (Groups 7 + 8), mother’s arms against reunion (Groups 3 + 4) versus (Groups 7 + 8), and nursery against reunion (Groups 5 + 6) versus (Groups 7 + 8). We found that the mothers who were not separated from their infants for the first 2 hours (Groups 1 + 2) and (Groups 3 + 4) were significantly less rougher (on the 1-5 scale) in their attempts to latch, than the mothers who were separated during the first 2 hours and then reunited with their infants at the maternity (for Groups 1 + 2 versus Groups 7 + 8, χ² = 8.622, p = .013, 4 df; and for Groups 3 + 4 versus Groups 7 + 8, χ² = 6.484, p = .039, 2 df).

Discussion

Findings indicate that separation of mother and baby at birth and swaddling of the newborn interfered with mother–infant interaction during a breastfeeding session at Day 4. Most important, these mothers significantly demonstrated more roughness in their behaviors with their infants at Day 4. As only bivariate statistics were used in this study, results must be interpreted with caution, especially because subgroups were small even if the sample was statistically adequate (Beck, 1994).

However, results show that babies who were in the nursery during the postnatal period were harder to wake up for feedings than babies who were rooming-in with their mothers, and that the separated mothers demonstrated more roughness in their behaviors during a breastfeeding session. This makes sense as mothers who were separated from their infants could neither observe their baby’s awakening behaviors nor their readiness to feed. In response, mothers demonstrated rougher behaviors to get their baby to wake up and to latch on to the nipple, stimulating them with more roughness, knowing they were encountering their babies only on a strict schedule to feed. In our study, mothers who were separated from their babies were in contact with them only on strict schedule of 7 times in 24 hours and with strict timing; those mothers may also have been rougher or insisted more roughly to get their babies to the breast, especially if they experienced difficulties in feeding a sleepy infant. Recognized authors have suggested that mother–infant proximity during the postpartum period predicts success of milk production, breastfeeding, and baby’s weight gain recovery (Bernard-Bonnin, Stachtenko, Girard, & Rousseau, 1989; Bystrova, Widström, et al., 2007; Perez-Escamilla, Pollitt, Lönnerdal, & Dewey, 1994; Yamauchi and Yamanouchi, 1990).

Proximity is known as the very first step in facilitating early mother–infant bonding and attachment (Ainsworth, 1973; Feldman, Weller, Zagoory-Sharon, & Levine, 2007; Kennel & Klaus, 1998; Klaus & Kennel, 1976; Lozoff, Brittenham, Trause, Kennel, & Klaus, 1977). Interaction and mutuality can develop starting as early as the first 2 hours after birth with the first cry followed by slow awakening, infant touch of the breast or suckling, and nonverbal calm communication (Leboyer, 1974, 1978; Wiberg, 1990; Widström, 1988; Widström et al., 2011). Skin-to-skin care and nonseparation are simple means to promote bonding, early attachment and maternal confidence in her mothering abilities (Barnett, Leiderman, Grobstein, & Klaus, 1970). When mother and baby are separated, this normal process is interrupted for both of them.

Our results show that maternal roughness during a breastfeeding session may also be attributed to the type of baby’s apparel. Mothers showed more roughness with their swaddled babies than with their clothed babies, irrespective of the separation from their babies or not. The video observations also illustrated that swaddled babies were sleepier and harder to wake up; in so doing, they were more difficult to get interested in the breast. Physiological and psychological events occurring during the very first 2 hours after birth are basic to the child’s and mother’s survival and health and may be obliterated by lack of close contact between mother and baby (Klaus, 1998). In fact, our results show that swaddling and separation disturb such normal mechanisms by impeding expected familiarization process of mother and newborn. Those demonstrated negative effects of swaddling add to what has been reported elsewhere, such as longer sleep, decreased spontaneous awakenings, increased respiratory infections, increased dysplasia of the hip (Franco et al., 2005; Gerard, Harris, & Thach, 2002a; Gerard et al., 2002b; Mahan & Kasser, 2008; van Sleuwen et al., 2007).

Moreover, results illustrated that mothers who were separated from their swaddled babies for the first 2 hours showed a reduced affective responsiveness to their infants: rougher movements to and from the baby, in trying to get the baby to latch on the nipple, and rougher stimulation of the baby. Generally speaking, and cross-culturally, separation and swaddling seem the worst combination for mother and baby to learn to cultivate a relationship as they do not have opportunities to get to know each other because of the distance and tight clothing impairing infant’s cues. We have detected a negative general affective responsiveness of mothers to their infants at Day 4 during a breastfeeding session when the babies were swaddled and in the nursery. This could suggest lack of early learning opportunities for the mothers related to the needs of their infants. Bystrova et al. (2009) demonstrated decreased sensitivity of mothers to their infants and less mutual reciprocity when children were 1 year of age when those dyads have been separated from birth. This behavior may have its origin during the few hours after birth, when mother and baby do not learn to feel and respond to each other. According to Barnett et al. (1970), mothers do not acquire self-confidence in their mothering capabilities when separated from their infants; authors call this “maternal side of interactional deprivation.”

Even if shown detrimental in many ways, swaddling is still recommended by some authors to calm babies, so they sleep more and cry less (Gerard et al., 2002a, 2002b; Karp, 2002; van Sleuwen et al., 2007), and to prevent sudden infant death syndrome by forcing infants in a supine position (Beal & Porter, 1991; Gerard et al., 2002b). This is not based on evidences and it is not an indisputable finding as many potential complications are reported with the use of swaddling (Kutlu, Memik, Mutlu, Kutlu, & Arslan, 1992; Lipton, Steinschneider, & Richmond, 1965; Oden et al., 2012; van Gestel, L’Hoir, ten Berge, Jansen, & Plötz, 2002; van Sleuwen et al., 2007; Yurdakok, Yavuz, & Taylor, 1990). Supine position coupled with breastfeeding and absence of parental smoking predict a better protection for sudden infant death syndrome (Academy of Breastfeeding Medicine Protocol Committee, 2008; Fleming, Tsogt, & Blair, 2006; National Institute of Child Health and Human Development, 2006; Perinatal services BC, 2011).

Different types of infant swaddling and bundling exist throughout the world, ancient and modern practices, for which risks and benefits may differ. No such differences are seriously documented in the literature. According to a systematic review from van Sleuwen et al. (2007), “most studies were descriptive and not randomized, uncontrolled, or comparative. Many results, therefore, comprised opinions and perceptions” (p. e1098). On the contrary, present results originate from a randomized controlled trial. We objectively showed significant ill effects on early mother–infant interaction because of separation and swaddling, the worst combination being the swaddled infants not rooming-in with their mothers. Our results also show that swaddling by itself (that the babies be separated or not) is a statistically significant variable of maternal roughness during a breastfeeding session at Day 4.

Swaddling hinders baby’s expressiveness and responsiveness, and so the mutual familiarization process with the mother. Swaddled babies are sensory deprived because of reduced internal and external stimulation. Can we still recommend restriction of newborns’ movements only for them to cry less and sleep more? To communicate their needs, newborns move their body, head, and mouth, they bring their fists to their mouth; they fuss or cry so as to alert adults with specific cues. If they are not capable of expressing such cues because of the swaddling or tight bundling, and if they are separated from their mothers, they do not get to know each other. In fact, swaddling and separation together excludes many opportunities for mothers to understand their babies’ signs and quickly learn from them. On the opposite, when seeing their swaddled babies only a few times a day, mothers then develop more roughness to bring them back to the reality of wakefulness and feeding. Babies may react by showing movements of avoidance to the breast, which results in ineffective breastfeeding sequence and then incorrect lactation process. Baby’s overt recoil movements are rarely observed in situations where he or she is not forced into feeding at all costs (Weimers, Svensson, Dumas, Navér, & Wahlberg, 2006). Occurrence of this behavior was not frequently observed in our videos but when it was, it was significantly associated with separation and swaddling.

The WHO-UNICEF Baby-Friendly Hospital Initiative (WHO, Division of Child Health and Development, 1998; WHO/UNICEF, 2009) recommends mother and baby rooming-in during whole postpartum stay at the birthing facility; mother–infant separations should be linked to medically justified interventions which cannot take place in the mother’s room. Our findings add to the scientific evidences for this international program. The early mother–infant interaction behaviors are related to bonding, influencing the capacity to take care of a child. Health professionals should encourage uninterrupted closeness to favor a positive and soft start in this relationship. Skin-to-skin contact and rooming-in may be the two most important recommendations in the Baby-Friendly Hospital Initiative (WHO, Division of Child Health and Development, 1998) that have helped reduce infant abandonment in Russia (Lvoff, Lvoff, & Klaus, 2000); we posit that proximity is probably the most important factor for a mother to develop this early bonding facilitating her attachment to her baby.

This uninterrupted proximity also needs to start at birth. In our study, mothers who have been separated from their baby immediately after birth and then reunited 2 hours later, showed a similar behavioral pattern as mothers who have been separated without reunion. In other words, mothers are rougher when separated from their infants and demonstrate no different behaviors on any variable when reunited with their babies 2 hours later. Maybe it can be advanced in simple terms that rooming-in cannot “repair” lack of proximity at birth. These results offer more evidences to previous suggestions of a 2-hour sensitive period when mothers and babies should not be separated unless medically justified (Bystrova, 2008; Kennel et al., 1975; Hales, Lozoff, Sosa, & Kennel, 1977). In fact, we demonstrated that when babies were skin-to-skin with their mothers or clothed in their arms at birth, the initial 2-hour period resulted in statistically significant maternal softness compared with the mothers of babies who were separated for a 2-hour period and then reunited.

Lack of uninterrupted skin-to-skin contact immediately after birth and early mother–infant separation are not specific to Russian culture; as in many countries, babies and mothers are separated early after birth. Babies are brought to the nursery for various reasons and duration. Results of an informal survey conducted in North America (Dumas & Lepage, 2007; Dumas, Lepage, & Grondin, 2007) show that babies are brought to the nursery for non-evidence-based reasons such as “Baby will be too cold,” “Mother had a caesarean section and will experience too much pain to take care of her baby,” “Baby needs to be measured, weighed, and to receive his routine care,” or “Father also needs early closeness with his baby.”

Results of our study add to previous researches which have suggested that both skin-to-skin contact and nonseparation are best for full-term healthy babies and mothers after birth (Bystrova et al., 2003; Bystrova, Matthiesen, Vorontsof, et al., 2007; Bystrova, Matthiesen, Widström, et al., 2007; Bystrova, Widström, et al., 2007; Carfoot, Williamson, & Dickson, 2003; Christensson, Bhat, Amadi, Eriksson, & Höjer, 1998; Christensson et al., 1992; de Château & Wiberg, 1977a, 1977b; Ferber & Makhoul, 2004; Fransson, Karlsson, & Nilsson, 2005; Moore, Anderson, & Bergman, 2007; WHO, Division of Child Health and Development, 1998; Winberg, 2005).

We also found that skin-to-skin groups and mother’s arms groups were very similar in their attempts at latching when compared with separated groups. Early and unrestricted access to the breast may be what is leveling the difference between skin-to-skin group and mother’s arms group by promoting early softness in those mothers. In fact, Bystrova, Widström, et al. (2007) showed that suckling within the first 2 hours made a difference on milk production at Day 4. Bystrova (2008) not only demonstrated that early suckling is central in the quicker recovery of the baby’s weight loss but also suggested that early suckling could be more important than skin-to-skin contact for milk production, suckling being an alternative sensory stimulation. This seems possible as suckling requires closeness to the mother, the mother’s skin, and to the mother’s odors (Porter & Winberg, 1999), which helps the release of hormones contributing to the development of positive maternal feelings and reduction of stress (Nissen et al., 1996). The mother is also calmer and more social during a breastfeeding session (Uvnäs-Moberg, Widström, Nissen, & Björvell, 1990) which could well start with the first suckling. In a study of babies all placed skin-to-skin with their mothers, Widström et al. (1990) found that early suckling made a significant difference in the mother–infant relationship during the first 4 days in postpartum; mothers who had their babies lick or touch their areola or nipple were more reluctant to leave their babies in the nursery for longer periods of time and they talked more to their infants during a breastfeeding session. As this was associated with maternal lower gastrin level, it suggests a hormonal influence on the mother behavior. This sensitive 2-hour window right after birth offers opportunity to trigger mother’s responsiveness to the needs of her offspring and should not be delayed as any interruption could significantly delay what has been described as the normal behavioral sequence in the human mammal baby (Widström et al., 2011).

One intriguing finding is that mothers who experienced skin-to-skin contact at birth and rooming-in with their babies afterwards showed significant objective demonstration of pain at latching over the mothers who had their clothed baby in their arms or those who were separated from their baby. We do not understand this finding. Perhaps these mothers were more sensitive? Maybe nonseparation and early skin-to-skin contact prompted them to focus more on their baby’s needs and less on their own? However, we believe it may be linked to a misunderstanding of the normal newborn sequence described by Widström et al. (2011), which is followed by babies placed skin-to-skin but not in babies either dressed or separated from their mothers. The skin-to-skin babies touch and lick the breast, and “train” their mouth and tongue on the breast before attaching to the nipple. Russian midwives are not trained to help mothers of nonswaddled babies. Thus, this normal process may have been interpreted by mother or the midwife not used to skin-to-skin contact at birth, as a need to quickly place the nipple in the baby’s mouth for early suckling, which is a frequent practice throughout the world, instead of letting the baby do it at his or her own rhythm. Offering the breast to a swaddled baby consists more of placing mouth directly in front of the breast.

Conclusion

Findings indicate that both swaddling and mother–infant separation at birth disturb normal expected maternal behaviors. Swaddling by itself seems to be detrimental to the early establishment of maternal–infant bonding, which, from an evolutionary perspective, is basic to baby’s survival. Perinatal practices should on the contrary encourage uninterrupted and unhurried skin-to-skin contact between mother and infant starting immediately after birth and rooming-in during following postpartum days. Practices to be avoided are swaddling or tight bundling of infants and mother–infant separation without medical justification. This research supports evidences of an early sensitive period for early mother–infant interaction during the first hours after birth, which should be protected by not separating mother and baby unless there is a medical emergency. Results from the present study add to the scientific evidences already available for the Ten Steps for Successful Breastfeeding (WHO, Division of Child Health and Development, 1998; WHO/UNICEF, 2009).

The validated tool proved easy to use for observation and coding of visual content of videos on mother–infant interaction during breast-feeding sequences, even for observers from different cultures. It appears a valid tool for research and clinical purposes, as only short training or self-training with the coding manual is necessary when coders are experienced perinatal clinicians.

Footnotes

Authors’ Note

Members of the validation committees for the assessment tool in this study by alphabetical order: K. Bystrova, L. Dumas, M. Edhborg, W. Jonas, A. B. Ransjö-Arvidson, K. Svensson, M. Velandia, B. Welles-Nyström, A.-M. Widström. The following researchers have been involved in some way in the longitudinal project over the years: from Russia by alphabetical order: late Dr K. Bystrova, V. Ivanova, K. Jakusheva, R. Mukhamedrakhimov, N. Romanova, O. Sajikova, late professor I. Vorontsov; from Sweden by alphabetical order: M. Edhborg, W. Lundh, A. S. Matthiesen, A. B. Ransjö-Arvidson, K. Uvnäs-Moberg, B. Welles-Nyström, C. Wassberg, A. M. Widström. This article is dedicated to our colleague and friend, Dr Ksenia Bystrova, who died too soon, leaving us with sadness but fond memories.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by grants from the Ministère de la Santé et des Services sociaux du gouvernement du Québec, and the Université du Québec en Outaouais. It is part of a longitudinal Russian–Swedish research project that was started after a Consensus conference initiated by the World Health Organization in St. Petersburg in 1991. The overall intent of this collaboration was to evaluate the influence of maternity homes’ (maternity hospitals where mothers give birth in Russia) perinatal practices on mother and infant variables. Grants for the original longitudinal study came from East European Committee, SIDA, Royal Swedish Academy of Science, Karolinska Institutet, Sällskapet Barnavård, St. Petersburg State Pediatric/Medical Academy, and The Swedish Institute.

Author Biographies

Louise Dumas, RN, MSN, PhD, is a professor-researcher at the Université du Québec en Outaouais, Department of Nursing Sciences, Québec, Canada, and a guest researcher at the Karolinska Institutet, Department of Woman and Child Health, Division of Reproductive and Perinatal Health, Stockholm, Sweden.

Mario Lepage, RN, MScN, PhD, is a professor-researcher at the Université du Québec en Outaouais, Department of Nursing Sciences, Québec, Canada.

Ksenia Bystrova, MD, PhD, was a pediatrician with the St. Petersburg Pediatric Academy, Department of Hospital Pediatrics, St. Petersburg, Russia, and a researcher at the Karolinska Institutet, Department of Woman and Child Health, Division of Reproductive and Perinatal Health, Stockholm, Sweden.

Ann-Sofi Matthiesen, PhD, is a researcher at the Karolinska Institutet, Department of Woman and Child Health, Division of Reproductive and Perinatal Health, Stockholm, Sweden.

Barbara Welles-Nyström, PhD, is a professor and researcher at the Department of Educational Studies and Teacher Preparation, Graduate School of Education and Allied Professions, Fairfield University, Fairfield, Connecticut.

Ann-Marie Widström, RNMTD, PhD, is a researcher at the Karolinska Institutet, Department of Woman and Child Health, Division of Reproductive and Perinatal Health, Stockholm, Sweden.

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Influence of Skin-to-Skin Contact and Rooming-In on Early Mother–Infant Interaction

Abstract

Keywords

Introduction

Material and Method

The Instrument

Statistical Considerations

Results

Discussion

Conclusion

Footnotes

Authors’ Note

Declaration of Conflicting Interests

Funding

Author Biographies

References