R E S E A R C H Open Access
The effect of mother and newborn early
skin-to-skin contact on initiation of
breastfeeding, newborn temperature
and duration of third stage of labor
, Awaz Aziz Saeed
, Shukir Saleem Hasan
and Lida Moghaddam-Banaem
Background: Mother and newborn skin-to-skin contact (SSC) after birth brings about numerous protective effects;
however, it is an intervention that is underutilized in Iraq where a globally considerable rate of maternal and child
death has been reported. The present study was conducted in order to assess the effects of SCC on initiation of
breastfeeding, newborn temperature, and duration of the third stage of labor.
Methods: A quasi-experimental study was conducted on 108 healthy women and their neonates (56 in the
intervention group who received SSC and 52 in the routine care group) at Hawler maternity teaching hospital
of Erbil, Iraq from February to May, 2017. Data were collected via structured interviews and the LATCH scale
to document breastfeeding sessions.
26.02 ± 5.94 (M ± SD) respectively. Based on the LATCH scores, 48% of mothers who received SSC and 46%
with routine care had successful breastfeeding. Newborns who received SSC initiated breastfeeding within 2.
41 ± 1.38 (M ± SD) minutes after birth; however, newborns who received routine care started breastfeeding in
5.48 ± 5.7 (M ± SD) minutes. Duration of the third stage of labor in mothers who practiced SSC after birth was
6 ± 1.7 min, compared to 8.02 ± 3.6 min for mothers who were provided with routine care (p< 0.001). Moreover, the
prevalence of hypothermia in the newborns who received SSC and routine care was 2 and 42% respectively. Results
remained unchanged after using regression modelling to adjust for potential factors and background characteristics.
Conclusion: Skin-to-skin contact provides an appropriate and affordable yet high quality alternative to technology. It is
easily implemented, even in small hospitals of very low-income countries, and has the potential to save newborns’and
mothers’lives. It is necessary to prioritize training of health providers to implement essential newborn care including
SSC. Community engagement is also needed to ensure that all women and their families understand the benefits of
SSC and early initiation of breastfeeding.
Trial registration: ClinicalTrials.gov: NCT03548389.
Keywords: Early skin-to-skin contact, Temperature, Third stage of labor, Initiation of breastfeeding
* Correspondence: email@example.com
Department of Nursing, College of Nursing, Hawler Medical University, Erbil,
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Safari et al. International Breastfeeding Journal (2018) 13:32
The rate of maternal and neonatal mortality is unaccept-
ably high in Iraq. The maternal and neonatal mortality
rates are as high as 84 cases per 100,000 live births and
23 cases per 1000 live births, respectively . These
figures are significantly higher in Iraq than developed
countries, for example neonatal mortality rates was re-
ported to be 1.74 per 1000 birth in the UK in 2015 .
Perinatal infections and fetal hypoxia are the most im-
portant causes of neonatal deaths in Iraq, which can be
avoided through early initiation of exclusive breastfeed-
ing . However, the prevalence of early initiation of
breastfeeding in Iraq is quite low at 38.1% .
As recommended by the Baby Friendly Hospital Initia-
tive (BFHI), newborn infants should be placed in
skin-to-skin contact with their mothers immediately
after their birth for at least one hour, and mothers
should be helped to initiate breastfeeding within the first
half-hour following the birth of their infants [4,5]. The
term skin-to-skin contact (SSC) is defined as the
placement of a naked infant, occasionally with a dia-
per or a cap on, on its mother’s bare skin, and the
exposed side/back of the infant covered by a blanket
or a towel . The movement of the infant’shands
over the mother breasts during SSC leads to increased se-
cretion of oxytocin, which results in increased secretion of
breast milk .
It is also known that SSC after birth promotes new-
born temperature regulation, metabolic adaptation, and
maintenance of glucose blood levels. Infants have a re-
duced capacity to generate heat, which leads to a rapid
decline in temperature. This is why maintenance of
temperature is one of the most important needs of in-
fants at birth . While the mother and her infant are in
SSC, heat is transferred from the mother to the infant,
during which the mother’s body temperature activates
the infant’s sensory nerves, which in turn results in the
infant’s relaxation, reduction in the tone of the sympa-
thetic nerves, dilation of skin vessels, and increase in its
temperature . Hypothermia during the newborn
period is widely regarded as a major contributory cause
of significant morbidity and, at its extreme, mortality in
developing countries . High prevalence of hypothermia
has been reported in countries with the highest rate of
neonatal mortality, where hypothermia is increasingly
gaining attention and significance as a critical intervention
for newborn survival .
In addition providing the newborn with numerous
benefits, SSC is associated with many benefits for
mothers. Secretion of maternal oxytocin in mothers who
receive SSC strengthens uterine contractions, which in
turn helps the placenta to separate and the duration of
the third stage of labor to decrease . The third stage
of labor, which involves separation and expulsion of the
placenta and membranes, starts immediately after the
delivery of the fetus . In most obstetric settings, ac-
tive management of the third stage of labor is now a
common practice to accelerate the third stage, in which
synthetic oxytocin that causes the uterus to strongly
contract is administered. In a spontaneous, uncompli-
cated birth, it is reasonable to plan a physiological or
natural third stage by utilizing the mother’s own oxyto-
There is an urgent need to reorganize and restructure
health services throughout Iraq, and maternity and neo-
natal care is one of the critical areas that needs substan-
tial efforts in this regard . As a cost-effective, simple
and appropriate method, mother and newborn SSC after
birth should be practiced in order to improve post-deliv-
ery care and potentially save the lives of mothers and
newborns . There are very few studies that focus on
the effects of SSC on maternal and newborn health in
Iraq. The present study was carried out in order to
determine the effect of early maternal-newborn SSC
after birth on the duration of the third stage of
labor, early initiation of breastfeeding, and newborn
To achieve the objectives of the study, the following
hypotheses were tested:
(1) Mothers who practice early mother and newborn
SSC after giving birth experience a shorter duration
of the third stage of labor compared with those who
do not practice SSC.
(2) Mothers who practice early mother and newborn
SSC after giving birth exhibit earlier initiation of
breastfeeding compared with those who do not
(3) Newborns with mother and newborn SSC exhibit
normal body temperature 30 min after birth
(4) Mothers who practice early mother and newborn
SSC after giving birth exhibit more successful
breastfeeding compared with those who do not
perform this contact.
A quasi-experimental study was conducted on 108
mothers and their neonates in the maternity department
of Hawler maternity teaching hospital in Erbil, Iraq from
February to May, 2017. Hawler maternity teaching
hospital is one of the largest and busiest maternity
hospital in Erbil. Erbil is a city that lies 80 km
(50 miles) east of Mosul, and is the capital of the
language spoken by residents is Kurdish .
Safari et al. International Breastfeeding Journal (2018) 13:32 Page 2 of 8
Of the 130 women who were eligible to participate in
this study, twenty-two women were unable to continue
SSC for 1 h after birth, therefore they were excluded.
Finally, we included results from 108 mothers in this
study who were randomized into two groups: an inter-
vention group consisting of 56 mothers; and the control
group consisting of 52 mothers.
Mothers in both groups were homogeneous in terms
of their age and gravidity. Laboring women and new-
borns who met the following conditions were included
in the study:
Full-term (38 to 42 weeks of gestation)
Anticipated normal vaginal delivery and desire to
breastfeed the infant at birth
Lack of receiving any pharmacological pain relief
Willing to join the study
Newborns with an Apgar score > 7
In this study SSC meant holding the newborn baby
undressed in a prone position against the mother’s bare
chest between breasts while the back of the baby was
covered with a blanket. This SSC commenced immedi-
ately after giving birth and continued for 1 h.
Four instruments were used to collect data. The first in-
strument was a questionnaire to gather the required
demographic and obstetric data from the mothers, in-
cluding age, gravidity, number of miscarriages, parity,
and history of lactation, along with the demographic
data of the infants, including weight and gender. The
second instrument was a written form that was used to
assess the duration of the third stage of labor, which was
measured from time of delivery of the infant to the time
of complete delivery of the placenta . The third in-
strument was a written form to record axillary tempera-
tures of the newborns. The fourth instrument was the
LATCH breastfeeding assessment tool. LATCH is a sen-
sitive, reliable and valid tool that evaluates breastfeeding
techniques based on observations and descriptions of ef-
fective breastfeeding [19,20]. The letters of the acronym
LATCH designate five separate assessment parameters:
“L”for how well the infant latches onto the breast, “A”
for the amount of audible swallowing, “T”for the
mother’s nipple types, “C”for the mother’s level of com-
fort, and “H”for the amount of support the mother has
be given to hold her infant to the breast. Each parameter
is scored using a numerical score of 0, 1, or 2 . The
LATCH scale was designed to assess the success of
breastfeeding in this study since it is a useful tool in
mother-infant pairs who might benefit from additional
skilled support to initiate breastfeeding in specific
subgroups at risk of non-exclusive breastfeeding at
The “L”assessment was scored as “2”if good latching
was identified (grasps breast, tongue down, lips flanged
and rhythmic sucking); “1”if repeated attempts to hold
the nipple in the mouth or to stimulate to suck were
identified, and “0”if poor latching (too sleepy or reluc-
tant or no latching achieved) was seen. The “A”assess-
ment was scored as “2”if audible swallowing occurred
(spontaneous and intermittent < 24 h old or spontan-
eous and frequent > 24 h old), “1”if a few swallows oc-
curred with stimulation, and “0”if ineffective
swallowing occurred. The “T”assessment was scored as
“2”if an everted nipple was present (after stimulation),
“1”if the nipple was flat, and ‘0’if the nipple was
inverted. The ‘C’assessment was scored as “2”if the
breast was soft and tender, “1”if the breast was filled or
reddened / featured small blisters / bruised nipples, and
“0”if the breast was engorged or if a crack appeared.
The ‘H’assessment was scored as “2”if good position-
ing was achieved (no assistance from the staff or
mother able to position / hold infant), “1”if minimal
assistance was required (i.e., elevate the head of the bed
or place pillows for support), and “0”if full assistance
was required (staff held the infant at the mother’s
breast) . The total score ranges from 0 to 10, with
the higher score representing efficient breastfeeding
techniques. A total score of more than 7 is regarded as
successful breastfeeding, and a score of less than 7 is
considered as unsuccessful breastfeeding .
Method of data collection
The midwives who worked regularly in the birthing suite
agreed that the researcher could attend and record ob-
servations of consenting mothers while they were being
provided with care. The midwives were requested to be-
have as if the researcher was not present and not to
make changes to their normal practice. The researcher
arrived at the delivery room, confirmed the consent of
the laboring woman and her relatives, and gained her
presence permission from the person managing the
birth. The observation equipment included the observa-
tion record sheet on a clipboard, a stopwatch, a therm-
ometer and a pen. When birth was imminent, the
researcher entered the room to observe. At the moment
of birth, the researcher started the stopwatch to record
the time following the birth. The researcher stayed with
each woman until the end of the first hour after birth.
In the routine care group, the infant was delivered by
a midwife, wrapped in blankets, placed under a warmer,
and then dried. The Apgar score was determined imme-
diately after the umbilical cord was cut. The infants were
provided with this routine care by the midwife working
in the delivery room. After the infants were weighed,
Safari et al. International Breastfeeding Journal (2018) 13:32 Page 3 of 8
dressed, and measured, they were handed to their
mothers who were encouraged to begin breastfeeding.
The routine care of placing a newborn under a warmer
is performed in the least time possible (4–5 min) in
Hawler maternity teaching hospital due to the presence
of only two warmers in the birthing suite for a five-bed
room, which are almost always occupied.
With the assistance of the researcher, infants in the
intervention group were placed undressed in a prone
position against their mothers’bare chest between
breasts immediately after birth and before placental de-
livery or suturing of tears or episiotomy. The Apgar
score was determined, the infant’s nose and mouth were
suctioned while on the mother’s chest, the infant was
dried, and both mother and infant were covered with a
pre-warmed blanket. To prevent heat loss, the infant’s
head was covered with a dry cap that was replaced when
it became damp. Dressing and measuring of the infant
were postponed to one hour after the delivery by a regis-
By standing behind or next to the bed and ap-
proaching closer to view the actions, the researcher
monitored the infants while they were exhibiting feeding
behaviors such as mouthing, licking, latching, and suck-
ling. Breastfeeding initiation time after birth and dur-
ation of the first breastfeed were recorded, and then the
LATCH scale was used to assess the success of the first
breastfeed in the two groups. Some of the mothers in
the two groups asked the researcher for assistance to
breastfeed their newborns; therefore, the degree of as-
sistance provided by researcher was scored along with
other parameters of the LATCH scale (latch, audible
swallowing, nipple type, comfort).
Active management of the third stage of labor was
performed for all participants by a registered midwife.
This composed of three steps: 1) administration of 10 IU
synthetic oxytocin, immediately after birth of the baby;
2) controlled cord traction (CCT) to deliver the placenta;
and 3) massage of the uterine fundus after the placenta
is delivered . The researcher did not interfere with
the delivery of the placenta and just observed this pro-
cedure being performed by the midwife. Duration of the
third stage of labor, which starts with the delivery of the
fetus and end with the complete delivery of the placenta
was measured by the researcher .
In the 1991 World Health Organization (WHO) guide-
lines it was recommended that rectal temperature
should be limited and axillary temperature should be
used routinely for the newborn . Therefore, in this
study, axillary temperature of the newborns in both
groups was checked 30 min after birth. The measuring
range of the thermometer was 32–42 °C with accuracy
to the nearest tenth of a degree. The thermometer sen-
sor was sterilized with 70% alcohol before each use.
After the button power was activated, the digital therm-
ometer was turned on and put with the sensor in the
newborn’s armpit, and kept there until the alarm sound
was heard. The score on the screen showed the mea-
sured body temperature. Based on WHO’s guidelines
(1991), an axillary temperature of less than 36.0 °C in
newborns is considered as hypothermia .
Data were analyzed using SPSS statistical analysis soft-
ware. Descriptive relationships between demographic
variables and type of care provided for mothers and
newborns after birth were explored using means and
standard deviations (SD) for continuous variables, whilst
categorical variables were described using proportions.
The relationship between SSC and time to initiate
breastfeeding, duration of third stage of labor, success of
breastfeeding, newborn hypothermia, and temperature
of the newborn 30 min after birth were analysed using T
tests and Chi square tests. Logistic regression modelling
was used to examine the effect of SSC and conventional
care on outcomes of the study by adjusting for potential
confounders like mother’s age, education level, occupa-
tion, parity, and newborn gender. The level of statistical
significance was set at p< 0.05 in this study. This study
had 100% power at a 95% level of confidence to detect
38 and 56% difference in initiation of the breastfeeding
and newborn temperature between mother-newborn
who experienced SSC and mother-newborns who under-
went routine care. The equivalent power value to de-
tect 17% differences in duration of third stage of
labor was 81%.
This study was carried out on 108 mothers and their
newborns. The results showed that mean age of the
mothers in the SSC and routine care groups was
26.29 ±6.13 (M ±SD) and 26.02 ±5.94 (M ±SD) re-
spectively. Higher numbers of the mothers in the routine
care group had secondary and academic education com-
pared with mothers in the intervention group. Most of
the mothers in both groups were non-employed and
multigravid. Approximately, the same proportion (50%)
of the mothers in both groups were primipara. The re-
sults showed that the two groups were not significantly
different in terms of the mothers’demographic charac-
teristics including maternal age, occupation, gravidity,
number of miscarriages, parity and number of antenatal
visits (Table 1). This study revealed that 48% versus 46%
of the newborns who experienced SSC or routine care
achieved successful breastfeeding, respectively (Table 2).
There was an association between mother and new-
born SSC and breastfeeding initiation time after birth.
Newborns who experienced SSC initiated breastfeeding
Safari et al. International Breastfeeding Journal (2018) 13:32 Page 4 of 8
2.41 ± 1.38 (M ± SD) minutes after delivery, while
newborns in the routine care group started breast-
feeding 5.48 ± 5.70 (M ± SD) minutes following their
birth (p< 0. 001).
As shown in Table 3, duration of the first breastfeed in
mothers with SSC versus routine care was 23.07 ± 7.89
(M ± SD) and 23.79 ± 8.22 (M ± SD) respectively; how-
ever, this difference was not statistically significant. In
mothers who practiced SCC, the duration of the third
stage of labor was significantly shorter than that of the
control group (6 ± 1.74 (M ± SD) versus 8.02 ± 3.69
(M ± SD) minutes) (p< 0.001). The average axillary
temperature of the newborns who experienced SSC
was 37.33 ± 0.65 °C, while it was 36.18 ± 0.99 °C in
newborns in the routine care group. It was found
that 98% of the newborns in the SSC group had nor-
mal temperature and 2% of them had hypothermia.
On the other hand, 42% the newborns in the routine
care group had hypothermia.
After using the regression model for adjustment of po-
tential factors and background characteristics such as
age, education level, employment, parity and newborn
gender, there was an association between newborn
temperature [Odds Ratio (OR) 0.01; 95% Confidence
Interval (CI) 0.002, 0.12] newborn hypothermia (OR
180.3; 95% CI 3.84, 8480), time to initiate breastfeeding
(OR 2.86; 95% CI 1.68, 4.85) and duration of third stage
of labor (OR 2.14; 95% CI 1.27, 3.6) with SSC (Table 4).
Fifty-two percent of the women in this study received
mother-newborn SSC immediately after birth, and 48%
experienced convention care after delivering their baby.
In this study, mothers in the SSC group had completed
lower levels of education compared to mothers in the
routine care group; however, this difference was not as-
sociated with the outcomes assessed in this study when
logistic regression analysis was applied. No relationship
was observed between other maternal characteristics
with SSC and routine care.
According to the results of the present study, contact
through the skin between the women and their new-
borns after birth led to greater initiation of breastfeed-
ing. It is not clear why SSC improved breastfeeding
behaviors of healthy full term infants, however, similar
findings have been reported in the literature . The
American College of Nurse-Midwives state that SSC
helps infants smell and find the nipple so that breast-
feeding will be initiated by them more rapidly and suc-
cessfully . This can be attributed to the high levels of
catecholamine immediately after birth, which makes ol-
factory bulbs in the infant’s nose extremely sensitive to
odor cues . The results of the studies carried out by
Moore and Anderson in USA , Khadivzadeh and
Karimi in Iran , and Mahmood et al. in Pakistan 
showed that early contact improved breastfeeding initi-
ation and prolonged the duration of breastfeeding in in-
fants. Early initiation of breastfeeding stimulates breast
milk production, produces antibody protection for the
newborn and its practice determines the successful es-
tablishment, longer duration of breastfeeding, and lower
risk of neonatal mortality .
In their study, Essa et al., using the Infant Breastfeed-
ing Assessment Tool (IBFAT), found that the SSC and
control groups were statistically different in terms of the
success of the first breastfeed rate . However, the
LATCH scale used in this study to assess the success
of breastfeeding found no statistical difference be-
tween the two groups. This discrepancy could be due
to a difference in the tools used to assess the success
Table 1 Maternal and newborn characteristics in SSC and routine
group (n= 52)
n (%) n (%)
- Maternal age
•Mean ± SD
26.29 ± 6.13
26.02 ± 5.94
- Mother’s education level
- Mother’s occupation
•Multi gravid (2–4)
- Number of miscarriage
Number of antenatal visit
- Gender of newborns
- Data are presented as mean (standard deviation) in case of continuous variables
and n (%) in case of frequencies
Safari et al. International Breastfeeding Journal (2018) 13:32 Page 5 of 8
Neonatal hypothermia is an important contributing
factor to neonatal mortality and morbidity in both devel-
oped and developing countries; especially in developing
countries . The Maternal and Child Health Program
by the WHO has issued guidelines for prevention of
neonatal hypothermia as one of the elements of essential
Table 2 Success of breastfeeding in mothers with skin-to-skin contact and routine care
Item Score Skin-to-skin contact
group (n= 56)
n (%) n (%)
Latch •(0) Too sleepy or reluctant, not latch obtained 1 (2) 0 (0%) 0.62
•(1) Repeated attempts, must hold nipple in
mouth, must stimulate to suck
30 (54%) 29 (56%)
•(2) Grasps breast, tongue down and forward,
lips flanged, Rhythmic suckling
24 (43%) 23 (44%)
Audible swallowing •(0) None
•(1) A few with stimulation
•(2) Spontaneous and intermittent
Type of nipple •(0) Inverted
•(2) Everett after stimulation
Comfort •(0) Engorged, cracked, bleeding, large blister,
0 (0%) 0 (0%)
•(1) Filling, Reddened, small blister or bruises,
mother complains, mild/moderate discomfort
6(11%) 6 (11%)
•(2) Soft, non- tender, intact nipple 50 (89%) 46 (88%) 0.89
Hold •(0) Full assist (staffs holds the baby at breast) 13 (23%) 19 (36%) 0.24
•(1) Minimal assistant, Teach one side mother - does
other staff holds and then mother take over
23 (42%) 20 (38%)
•(2) No assist from staff, mother able to position
and hold the infant
20 (36%) 12 (23%)
Total score •> 7 (Successful breastfeeding)
•< 7 (Unsuccessful breastfeeding)
Note: LATCH scale  was used in this study to assess success of breastfeeding
*Chi square test
Table 3 Comparison of breastfeeding behaviors, newborn
temperature and third stage of labor between groups
Items Skin-to-skin contact
group (n= 56)
group (n= 52)
- Time to initiate breastfeeding (minute)
•(Mean ± SD)
2.41 ± 1.385
5.48 ± 5.704
- Duration of first breastfeed(minute)
•(Mean ± SD)
23.07 ± 7.89
23.79 ± 8.22
- Temperature of newborns (degree Celsius)
•(Mean ± SD)
37.33 ± 0.65
36.18 ± 0.99
- Newborn hypothermia
- Duration of third stage of labor (minute)
•(Mean ± SD)
6 ± 1.7
8.02 ± 3.6
Chi square test
Table 4 Adjusted relationship of breastfeeding behaviors,
newborn temperature and third stage of labor with SSC
Items Odd Ratio (95%
- Maternal age 0.93 (0.76, 0.1) 0.53
- Maternal education 2.5 (0.98, 11) 0.06
- Occupation 0.69 (0.01, 27.04) 0.84
- Number of para 2 (0.92, 4.71) 0.07
- Newborn gender 0.22 (0.04, 1.19) 0.08
- Time to initiate breastfeeding 2.86 (1.68, 4.85) < 0.001
- Duration of first breastfeed 0.96 (0.86, 1.08) 0.53
- Duration of third stage of labor 2.14 (1.27, 3.6) 0.004
- Successful breastfeeding 0.8 (0.55, 1.17) 0.26
- Newborn temperature 0.01 (0.002, 0.12) < 0.001
- Newborn hypothermia 180.3 (3.84, 8480) 0.008
Safari et al. International Breastfeeding Journal (2018) 13:32 Page 6 of 8
care in the newborn at birth and on the first day of life
. In the present study, 42% of the newborns who did
not receive SSC care had hypothermia; however, just 2%
of the newborns who received SSC developed
hypothermia after birth. In their study on 160 term neo-
nates in Iran, Keshavarz and Haghighi investigated the
effects of kangaroo contact on physiological variables
after cesarean section. In so doing, the neonates were
randomly assigned into a SSC group and a routine care
group. The newborns’temperatures in both groups were
measured half an hour after the cessation of contact.
The mean temperature was significantly different in the
SSC and routine care groups (36.8 °C and 36.6 °C re-
spectively), and the mean temperature one hour after
SSC was 36.9 °C, which was 0.3 °C higher than the mean
temperature in the control group ( = 0.001) . The
results of a meta-analysis comprised of 23 studies indi-
cated strong evidence of increased body temperature as
a result of SSC. It is interesting to note that the ambient
temperature did not influence the outcome of body
temperature, as even in colder environments the body
temperature of newborns who received SCC increased
or at least remained unchanged . Transfer of heat
from the mother to the newborn facilitated by direct
skin contact has been demonstrated to be at least as ef-
fective as incubator care for warming .
Assessing the effect of SSC on duration of the third
stage of labor in the present study showed that the
mothers who had SSC with their infant after birth had a
shorter third stage in comparison with those who re-
ceived routine care (6 min vs 8.02 min). Similar findings
have been reported in a study carried out in Baghdad,
Iraq by Mejbel and Ali to examine the effectiveness of
SSC on the duration of the third stage of labor . In
an Egyptian investigation of low risk primiparous
women who either received SSC or routine hospital care,
the mean duration of the third stage of labor in the SSC
group was significantly shorter (2.8 ± 0.85 min) than the
routine care group (11.22 ± 3.33 min) (p< .01) .
Common practices used in the management of third
stage of labor neither facilitate the production of a
mother’s own oxytocin nor reduce catecholamine levels
during the first minutes after birth, both of which can be
expected to physiologically improve the new mother’s
contractions and thus reduce her blood loss. The routine
practice of separating mother and infant deprives the
mother of important opportunities to increase her nat-
ural oxytocin levels .
The results of the present study need to be considered
in the light of its limitations. In this study, there were no
data on exclusive breastfeeding, and duration of breast-
feeding was not assessed. In future studies, it would be
beneficial to look at exclusive breastfeeding after dis-
charge through a longitudinal study. The researcher of
the present study was faced with some challenges in fa-
cilitating SSC for the mothers in the intervention group.
This may have been because mothers in this study had
low knowledge regarding SSC care, as a result of poor
provision of health education at antenatal care units in
primary health care center in Erbil: only 23.7% of visiting
women receive education about infant care and breast-
feeding . Increased workload in the obstetric unit
did not allow the researcher to continue SSC more than
one hour after birth, although most of the mothers were
very pleased and enjoyed the experience of SSC and
wished to prolong its duration.
Conclusion and recommendations
To reduce the current prevalence of high neonatal mor-
bidity and mortality rate in Iraq, there is a dire need for
simple and cost-effective prevention and (complemen-
tary) intervention methods that are easily accessible to
mothers and can be applied immediately after birth.
Mother and newborn SSC is a low-cost intervention that
would be accessible, simple, and feasible for most
mothers in developing countries. In order to accomplish
this goal, the old paradigms of labor and delivery care
need to be changed and immediate, uninterrupted SSC
after birth should be practiced. Unlimited opportunities
for SSC and breastfeeding promote optimal maternal
and child outcomes. It is critical to provide all midwives
in delivery rooms with continuous educational and train-
ing programs on how to implement SSC for all mothers.
These changes directly support the millennium goals of
improved maternal and child health.
The authors would like to thank the delivery room staff of Hawler maternity
teaching hospital of Erbil, Iraq for their cooperation.
Availability of data and materials
The datasets analysed during the current study are available from the
corresponding author on reasonable request.
SAA and SK completed the data collection for this study. SK and HSS participated
in the design of the study and performed the statistical analysi s. SK and SA A
conceived the study, participated in its design and coordination, and
helped to draft the manuscript. MBL, HSS, and SK reviewed and revised
the manuscript. All authors read and approved the final manuscript.
Ethics approval and consent to participate
The participants gave informed consent for the data collection and ethical
approval for the data collection was granted by ethical committee of the
Nursing College of Hawler Medical University (Ref no. 20).
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Safari et al. International Breastfeeding Journal (2018) 13:32 Page 7 of 8
Department of Nursing, College of Nursing, Hawler Medical University, Erbil,
Department of Midwifery and Reproductive Health, Faculty of Medical
Sciences, Tarbiat Modares University, Tehran, Iran.
Received: 20 December 2017 Accepted: 9 July 2018
1. UNICEF, Iraq Ministry of Health Child and Maternal Mortality Survey, 1999.
Preliminary report. Iraq, July 1999:3–16.
2. Manktelow BM, Smith LK, Evans TA, Hyman-Taylor P, Kurinczuk JJ, Field DJ,
et al. MBRRACE UK collaboration. Perinatal mortality surveillance report –UK
perinatal deaths for births from January to December 2013. The Infant
Mortality and Morbidity Group, Department of Health Sciences, University of
Leicester: Leicester, UK, 2015.
3. Shaker NZ, Hasan SS, Ismail ZA. Impact of a baby-frien dly hospital on
breastfeeding indicators in Shaqlawa district in Erbil governorate, Kurdistan
region of Iraq. East Mediterr Health J. 2016;21(12):885–90.
4. WHO. CHD. Evidence for the Ten Steps to successful breastfeeding. Geneva:
World Health Organization; 1998.
5. WHO.UNICEF. Baby-friendly hospital initiative, revised updated and expanded
for integrated care. Geneva: WHO press, World Health Organization; 2009.
6. UNICEF (2011). How to implement baby friendly standards –a guide for
7. Jonas W, Wiklund I, Nissen E, Ransjo-Arvidson A, Uvnas-Moberg K. Newborn
skin temperature two days postpartum during breastfeeding related to
different labour ward practices. Early Hum Dev. 2007;83(1):55–62.
8. Price DL, Gwin JF, Price DL. Thompsons Pediatric Nursing. 9th ed. Philadelphia,
PA: Elsevier; 2006. Chapter 5: the high-risk neonate. p. 78–9.
9. Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L. Evidence-
based, cost-effective interventions: how many newborn babies can we save?
10. Ellis M, Manandhar N, Shakya U, Manandhar DS, Fawdry A, Costello AM.
Postnatal hypothermia and cold stress among newborn infants in Nepal
monitored by continuous ambulatory recording. Arch Dis Child Fetal
Neonatal Ed. 1996;75:F42–5.
11. Kiss A, Mikkelsen JD. Oxytocin--anatomy and functional assignments: a mini
review. Endocr Regul. 2005;39(3):97–105.
12. Buckley SJ. Leaving well alone: a natural approach to the third stage of
labour. Medical Veritas. 2005;2(2):492–9.
13. Burke C. Active versus expectant management of the third stage of labor
and implementation of a protocol. The journal of perinatal & neonatal
14. Royal College of Midwives. Evidence based guidelines for midwifery-led
Care in Labour. Care of the perineum, 2012.
15. Shabila NP, Ahmed HM, Yasin MY. Women’s views and experiences of
antenatal care in Iraq: a Q methodology study. BMC Pregnancy and
16. Boundy EO, Dastjerdi R, Spiegelman D, et al. Kangaroo Mother Care and
Neonatal Outcomes: A Meta-analysis. Pediatrics. 2016;137(1):e20152238.
17. Central Organization for Statistics and Information Technology (Iraq). Iraq
Living Conditions Survey 2004.
18. McDonald S. Management of the third stage of labor. Journal of Midwifery
& Women’s Health. 2007;52(3):254–61.
19. Jensen D, Wallace S, Kelsay P, LATCH. A Breastfeeding charting system and
documentation tool. PsycTESTS Dataset. 1994;23(1):27–32.
20. Lau Y, Htun TP, Lim P, Klainin-Yobas P. Psychometric evaluation of 5- and
4-item versions of the LATCH breastfeeding assessment tool during the
initial postpartum period among a multiethnic population. PLoS One. 2016;
21. Tornese G, Ronfani L, Pavan C, Demarini S, Monasta L, Davanzo R. Does the
LATCH score assessed in the first 24 hours after delivery predict non-exclusive
breastfeeding at hospital discharge? Breastfeed Med. 2012;7(6):423–30.
22. World Health Organization. Geneva: World Health Organization; 1991.
Thermal Protection of the Newborn: A Practical Guide. Report No.: WHO/
23. Schiffman RF. Temperature monitoring in the neonate: a comparison of
axillary and rectal temperatures. Nurs Res. 1982;31:274–7.
24. Aghdas K, Talat K, Sepideh B. Effect of immediate and continuous mother–
infant skin-to-skin contact on breastfeeding self-efficacy of primiparous
women: a randomized control trial. Women and Birth. 2014;27:37–40.
25. American College of Nurse-Midwives. Promoting skin -to-skin contact.
Journal of Midwifery & Women’s Health. 2013;58(3):359–60.
26. Righard L, Alade MO. Effect of delivery room routines on success of first
breastfeed. Lancet. 1990;336:1105–7.
27. Moore E, Anderson G. Randomized controlled trial of very early mother-
infant skin-to-skin contact and breastfeeding status. Journal of Midwifery &
Women’s Health. 2007;52(2):116–25.
28. Khadivzadeh T, Karimi A. The effects of post-birth mother-infant skin to skin
contact on first breastfeeding. Iran J Nurs Midwifery Res. 2009;14(3):111–6.
29. Mahmood I, Jamal M, Khan N. Effect of mother-infant early skin-to-skin
contact on breastfeeding status: a randomized controlled trial. J Coll
Physicians Surg Pak. 2011;21(10):601–5.
30. Takahashi K, Ganchimeg T, Ota E, Vogel JP, Souza JP, Laopaiboon M. Prevalence
of early initiation of breastfeeding and determinants of delayed initiation of
breastfeeding: secondary analysis of the WHO global survey. Sci Rep. 2017;7:
31. Essa RM, Ismail NIAA. Effect of early maternal/newborn skin-to-skin contact
after birth on the duration of third stage of labor and initiation of breastfeeding.
Journal of Nursing Education and Practice. 2015;5(4):98–107.
32. World Health Orga nization. Mother-baby package: implementing safe
motherhood in countries. Geneva: World Health Organization; 1994.
33. Keshavarz M, Bolbol HN. Effects of kangaroo contact on some physiological
parameters in term neonates and pain score in mothers with cesarean
section. Koomesh. 2010;11(2):91–8.
34. Moore ER, Anderson GC, Bergman N, Dowswell T. Early skin-to-skin contact
for mothers and their healthy newborn infants. Cochrane Database Syst
35. Christensson K, Bhat GJ, Amadi BC, Eriksson B, Hojer B. Randomised study of
skin-to-skin versus incubator care for rewarming low-risk hypothermic
neonates. Lancet. 1998;352:1115.
36. Mejbel M, Ali R. Effectiveness of skin-to-skin contact on duration of third
stage of labo r in Baghdad teaching hospital: comparative study. Kufa
Journal for Nursing Sciences. 2012;2(3):1–13.
Safari et al. International Breastfeeding Journal (2018) 13:32 Page 8 of 8
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