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Table of Contents
RESEARCH ARTICLE
Year : 2020  |  Volume : 21  |  Issue : 1  |  Page : 38-43

Effectiveness of early initiation of breastfeeding on maternal satisfaction with breast feeding among women who have undergone caesarean section and the breastfeeding behaviour of their newborns


1 Nursing Officer, All India Institute of Medical Sciences, New Delhi, India
2 Professor, College of Nursing, CMC, Vellore, Tamil Nadu, India
3 Professor, Department of Obstetrics and Gynaecology, CMC, Vellore, Tamil Nadu, India
4 Lecturer, Department of Biostatistics, CMC, Vellore, Tamil Nadu, India

Date of Submission18-Jan-2019
Date of Decision07-May-2020
Date of Acceptance26-May-2020
Date of Web Publication14-Sep-2020

Correspondence Address:
Mrs. Rachel Babu Kutty
All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCN.IJCN_46_20

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  Abstract 

Caesarean sections (CSs) are on a rise globally, with the aim of improving the maternal and newborn outcomes. However, separation of the mother and the baby after caesarean is the most common problem encountered. This is found to be a barrier to early initiation of breastfeeding after CS. An experimental study was conducted to determine the effectiveness of early initiation of breastfeeding on maternal satisfaction and the breastfeeding behaviour of the newborns. A total of 80 women and their newborns were recruited and randomly allocated to experimental group and control group. Breastfeeding was initiated for the experimental group in the recovery room, while for the control group it was initiated in the postnatal ward. The breastfeeding behaviour was assessed using the Preterm Infant Breastfeeding Behaviour Scale, a standardised tool, at the first and second breastfeeding sessions. Maternal satisfaction was assessed using the Maternal Breastfeeding Satisfaction Scale developed by the investigator. The experimental group showed significantly better breastfeeding behaviour than the control group at the first and second breastfeeding after birth with a statistical significance of P < 0.05 the first time and P < 0.001 for the second time. The mean score of maternal satisfaction of breastfeeding amongst women who belonged to the control group was 33.8 as compared to the mean score of 44.07 in the experimental group and the difference highly significant (P < 0.001). Hence, early initiation of breastfeeding is necessary to improve the maternal satisfaction and the breastfeeding behaviour of the newborn

Keywords: Breastfeeding, breastfeeding behaviour, caesarean section, early initiation, newborn


How to cite this article:
Kutty RB, Benjamin EE, Thomas E, Sebastian T. Effectiveness of early initiation of breastfeeding on maternal satisfaction with breast feeding among women who have undergone caesarean section and the breastfeeding behaviour of their newborns. Indian J Cont Nsg Edn 2020;21:38-43

How to cite this URL:
Kutty RB, Benjamin EE, Thomas E, Sebastian T. Effectiveness of early initiation of breastfeeding on maternal satisfaction with breast feeding among women who have undergone caesarean section and the breastfeeding behaviour of their newborns. Indian J Cont Nsg Edn [serial online] 2020 [cited 2020 Oct 23];21:38-43. Available from: https://www.ijcne.org/text.asp?2020/21/1/38/295043


  Introduction Top


Increasing caesarean delivery rates are a pressing public health concern. In the present scenario, the caesarean section (CS) rates have increased globally; which holds true for India too. According to the World Health Statistics of 2012, amongst the total births, 16% globally, 9% in South-East Asia, 9% in India were delivered by CS. India also shows a steady rise in CSs from 7% in 1998–1999 to 8.5% in 2008 to 9% in 2012. According to the World Health Organization (WHO),[1] 12.7% of the total CSs in 2008 were unnecessary.

This increase in CS in the recent years is based primarily on the desire to improve the physical outcome of the mother and her newborn, but the initiation of mothering role is often delayed due to delayed maternal-child contact which in turn delays the initiation of breastfeeding.[2] Thus CS was found to be a barrier to early initiation of breastfeeding.[3]

According to Anisfeld and Lipper,[4] early initiation ensures success in breastfeeding as sucking reflex is most active and babies are more alert during the first 30–60 min. Suction pressure exerted by the baby on sucking begins at birth, peaks at 90 min and decreases at 4 h.[5] The sucking behaviour of the infant is related to the behavioural states, as there is an increase in sucks generated by infants who are alert and crying than who are in a sleep or quiet awake state.[6] Breastfeeding behaviour, which is crucial to the establishment of lactation, includes latch-on, sucking and the coordination of sucking with swallowing and breathing. This is well elicited when the infant is awake and alert, so if babies are put to mother's breast within this period, chances of exclusive breastfeeding increases.[7],[8]

Shortening the duration of mother–infant separation is important to support breastfeeding. The increased incidence of breastfeeding and its continuation is the result of implementation of kangaroo care which is based on extended mother-infant skin to skin contact and early initiation of suckling at the breast.[9] There is an increase in exclusive breastfeeding at discharge when breastfeeding is initiated within 1 h of birth even when skin to skin contact was not provided.[10]

The WHO recommends that, breastfeeding has to be initiated within 1 h of delivery. The Ministry of Health and Family Welfare, India,[11] reports that the percentage of newborns in India who were breastfed within 1 h of birth was 63.3% in 2009–2010, 71.5% in 2010–2011, 79.2% in 2011–2012 and 82.3% in 2012–2013. Although the rate of breastfeeding initiation in India as a whole is encouraging, the percentage of newborns who were breastfed within 1 h of birth in Tamil Nadu was 72.3% in 2009–2010, 76.8% in 2010–2011, 72.6% in 2011–2012 and 67.2% in 2012–2013. The above-mentioned statistics shows that there has been a gradual decrease in the percentage of newborns who were breastfed within the 1st h of life in Tamil Nadu even when the overall percentage in India showed a marked increase.

Early initiation of breastfeeding within 1 h of the delivery promotes enhanced mother–infant interaction and improves the maternal and infant bonding when compared to initiation of breastfeeding after 1 h of delivery.[8],[12] The factors that influence the maternal satisfaction with breastfeeding are knowledge about breastfeeding, attitude toward breastfeeding, intention of breastfeeding, perceived encouragement of breastfeeding and self-efficacy of breastfeeding.[13] Mother's satisfaction with breastfeeding after a caesarean is greater when breastfeeding is started early but the satisfaction measures of initiating breastfeeding are poorly reported.[14],[15]

In the tertiary care centre in Tamil Nadu where the study took place, the investigator has observed that breastfeeding is unduly delayed after CS due to various reasons such as delay in shifting the mother to postnatal ward from the operation theatre and no provision to initiate breastfeeding in the recovery room of the operation theatre. Hence, the investigator was interested to evaluate the effectiveness of early initiation of breastfeeding in improving breastfeeding behaviour of the newborn and the maternal satisfaction with breastfeeding amongst women who had undergone CS. The objectives of the study were to compare the effectiveness of early initiation of breastfeeding on newborn breastfeeding behaviour and maternal satisfaction with breastfeeding in experimental group and control group and find association with selected demographic and clinical variables.


  Methods Top


An experimental design was adopted for this study. The study was conducted in the recovery room of the operation theatre and maternity wards. A total of 80 women who delivered by CS between 37 and 42 weeks of gestational age, who understood English or Tamil languages and whose newborns had an APGAR score of ≥7 at 1 min and ≥9 at 5 min and birth weight of 2.5 kg to 4.0 kg were recruited along with their newborns and were randomly allocated into control or experimental groups using computer generated random numbers.

Instrument

The instruments used for the study consisted of a demographic and clinical pro forma of the women and their newborns, Preterm Infant Breastfeeding Behaviour Assessment Scale (PIBBS), a standardised tool developed by Hedberg Nyqvist and Maternal Breastfeeding Satisfaction Scale developed by the investigator.[16]

The PIBBS was used to observe the breastfeeding behaviours such as rooting, areolar grasp, longest duration of latching on, sucking, longest sucking burst and swallowing. The inter-rater reliability for each aspect of breastfeeding behaviour ranged between 0.64 and 1.00 Cohen's kappa value. Each of the breastfeeding behaviour was given a numerical score to yield a total score of 0–20, depending on the breastfeeding behaviour of the baby. The PIBBS was scored as ineffective breastfeeding behaviour (0–6), moderately effective breastfeeding behaviour (7–15) and effective breastfeeding behaviour (16–20). The higher the score the better the breastfeeding behaviour.

The Maternal Breastfeeding Satisfaction Scale, a 5-point Likert Scale was used to assess the satisfaction of the mothers after the initiation of breastfeeding. The content validity of each item was calculated and the Content Validity Index of the instrument was 0.89. The reliability of the tool was assessed during the pilot study. The possible range of total score is 10–50, with higher scores indicating a higher degree of maternal satisfaction with breastfeeding.

Data collection

The data were collected for 6 weeks from the women undergoing CS and their newborn. An informed written consent was obtained from women posted for elective and emergency CS who fulfilled the inclusion criteria.

After the CS, the women and their newborns who fulfilled the inclusion criteria were randomised into experimental group or control group using computer generated numbers. The first mother and the newborn who met the inclusion criteria were selected as the first sample and the next sample was selected after the complete observation of the previous subject.

For the experimental group, after the birth of the baby, the newborn was shifted to the radiant warmer immediately after cutting the cord. The newborn was cleaned and wrapped with pre-warmed sheet and kept under the radiant warmer in recovery. Once the woman arrived to the recovery room of the operation theatre within 1 h of the delivery, breastfeeding was initiated. The first breastfeeding behaviour of the newborn was assessed by the investigator in the recovery room. The investigator then accompanied the women to the maternity ward when she was shifted. The second breastfeeding commenced in the ward and the breastfeeding behaviour was assessed.

For the control group, standard care was followed which included shifting the newborn to the radiant warmer immediately after cutting the cord. The newborns were cleaned and wrapped with pre-warmed sheet and transferred to the maternity ward where the mother would go after the surgery. The investigator accompanied these women to the postnatal ward when they were shifted from the recovery room. Breastfeeding was initiated when the mother reached the maternity ward. The breastfeeding behaviour of the newborn was assessed by the investigator for the initial two breastfeeding sessions.

The maternal satisfaction of breastfeeding in both experimental and control groups was assessed by the investigator on the 3rd day after CS.

The data collected were represented using descriptive and inferential statistics. Comparison between experimental and control groups was done using independent samples t-test. The association of maternal breastfeeding satisfaction and newborn breastfeeding behaviour with demographic and clinical variables was assessed using Chi-square test.


  Results and Discussion Top


The analysis of the demographic and clinical variables revealed that majority of the women enrolled in the study belonged to the age group of 25–30 years and 87.5% were homemakers. About 62.5% of the women were multiparous and almost 40% of the women delivered by 38 completed weeks of gestational age. The mean (±standard deviation [SD]) birth weight of the newborns was 3148 g (396.72). Among the 80-term newborns born to these women, 36 (45%) were female and 44 (55%) were male. The control group and experimental group did not differ in age, occupation, parity, type of previous delivery if multiparous, gestational age at delivery, birth weight of the newborns, sex of the baby and APGAR score at 1 and 5 min. A significant difference between the control group and experimental group was found for education of the women (χ2 = 15.127, P = 0.002), where 70% of the women in the control group were graduates when compared to only 42.5% of the women in experimental group.

In this study, the mean time taken to initiate breastfeeding after birth in the control group was 141.9 min amongst which 72.5% babies were initiated after 120 min, while the mean time taken for the initiation of breastfeeding in the experimental group was 46.5 min and all babies were first breastfeed within 60 min. In a study which implemented a nursing intervention protocol to minimise the maternal-infant separation after CS, revealed that mean time taken for mother-infant first physical contact was 15 min (SD ±99) in the control group and 6 min (SD ±2) in the interventional group (P = 0.001). Furthermore, the mean time taken for initiating breastfeeding was 90 (SD ±72) min in the control group and 49 (SD ±12) min in interventional group (P = 0.03)[17] showing that irrespective of the initiation of mother-infant contact after CS the recommended time for early initiation of breast feeding could not be followed in control group in both studies when there was no specific intervention. The findings are also supported by the study conducted by Rowe-Murray and Fisher [18] which reveals that the mean time taken to first breastfeed the baby is significantly higher amongst the women who underwent CS emphasising the need for specific intervention.

Most of the newborns in the experimental group for whom breastfeeding was initiated within 1 h of birth were active and alert during the initiation of first and second session of breastfeeding as evidenced by latching on to the breast with a median time of 10 s and 60 s, respectively. The newborns in the control group took a median time of 120 s and 300 s to latch on to the breast, during the initiation of first and second session of breastfeeding respectively as the newborns were found to be asleep and drowsy.

The experimental group showed significantly better breastfeeding behaviour than the control group at the first and second breastfeeding after birth with a statistical significance of P < 0.05 the first time (except for swallowing) and P < 0.001 for the second time (except for areolar grasp and swallowing) [Table 1] and [Table 2]. The rooting behaviour was positive in higher proportion of newborns in this group at both times (92.5%, 70%) compared to control group (40%, 22.5%). Majority of the newborns in experimental group also showed good areolar grasp (97.5%, 97.5%) and longer latch time (85%, 90%) compared to control group (82.5%, 92.5% and 57.5%, 35%) respectively, at both times of assessment [Figure 1] and [Figure 2]. Good attachment to breast and effective sucking is essential for successful breastfeeding.[19] The current study findings also revealed majority in the experimental group had longest sucking bursts at both times and the difference in mean for sucking burst was significantly lesser in control group predominantly in the second time (P < 0.001) of breast feeding [Table 2]. A study done by Medoff-Cooper et al.[6] revealed that the burst duration was affected by the state of the newborn, i.e., newborns who were awake and crying demonstrated an increase in burst duration relative to those newborns who were asleep or drowsy, but they did not show a significant difference in the mean frequency of sucks within the burst. Hence, infant state is a determinant of the sucking pattern in the newborn infant. As the newborns are more alert during the initial 1 h after birth, initiating breast feeding during this time will promote sucking burst which will promote milk flow through increase of prolactin.[20] In harmony with the findings of this study, a study conducted in Kumbakonam of South India found that when the newborns born by CS were immediately put on to the breast for breastfeeding, almost 98% of these newborns sucked immediately.[21] A study done in California reported that there was no statistically significant association between breastfeeding the baby within 1 h of birth and the suboptimal breastfeeding behaviour of the baby; however, an association was present between failure to breastfeed within 1 h of birth and (P < 0.1) delay in lactation.[22] Early initiation of breast feeding in women undergoing CS is essential to promote breastfeeding behaviour in newborns.
Table 1: Comparison of newborn breastfeeding behaviour during the first breastfeeding in control and experimental groups

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Table 2: Comparison of newborn breastfeeding behaviour during the second breastfeeding in control and experimental groups

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Figure 1: Newborn breastfeeding behaviour during the first breastfeeding in control and experimental groups.

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Figure 2: Newborn breastfeeding behaviour during second breastfeeding in control and experimental groups.

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The association between the newborn breastfeeding behaviour and the demographic and clinical variable was calculated using Chi-square and this showed no statistically significant association during the first breastfeeding but during the second breastfeeding session, the education of the women and the birth weight of the newborn were found to show statistically significant association (P < 0.05). It is found that effective breastfeeding behaviour of the newborn increased with increase in the birth weight of the newborns. Newborns of women with higher education exhibited better breastfeeding behaviour. According to Hedberg Nyqvist and Ewald,[9] lower educational level of the women had a positive effect on infant breastfeeding behaviour which is contrary to the findings of the present study. However, this finding was not elaborated in their study. The association of higher birth weight with efficient breastfeeding behaviour in Nyqvist and Ewald's study is congruent with the findings of the present study.

A study done in California to determine the incidence and risk factors for suboptimal infant breastfeeding behaviour used Infant Breastfeeding Assessment Tool score for assessing the breastfeeding behaviour of the infant, found that maternal factors such as primiparity was associated with suboptimal infant breastfeeding behaviour on day 0 (P < 0.05) and they also had delayed onset of lactation. The maternal age of <30 years was associated with suboptimal infant breastfeeding behaviour on day 7 (P < 0.05). This study showed that education of the mother and pregnancy weight gain was not statistically associated with the breastfeeding behaviour of the infant. Infant factors such as sex, birth weight and gestational age were not statistically associated with suboptimal breastfeeding behaviour of the infant. An Apgar score of ≤7 was statistically (P < 0.1) associated with suboptimal breastfeeding behaviour of the infant on day 3. These results were contrary to the findings of the present study.[22]

The mean score of maternal satisfaction of breastfeeding amongst women who belonged to the control group in the present study was 33.8 as compared to the mean score of 44.07 in the experimental group and was found to be highly significant (P < 0.001). In percentages, majority of the women (90%) in control group scored their satisfaction <40 while the majority of women (80%) in the experimental group scored their satisfaction more than 40. This finding is congruent with a study conducted in Japan which reported an association of early initiation with maternal satisfaction. The mothers verbalised that they felt calm, had the pleasure of breastfeeding and felt motherly love.[23] Another qualitative study which analysed the experience and feeling of the mothers who underwent CS with regard to the first contact with the baby found that, the mothers who breastfeed their babies within 1 h of delivery verbalised the feeling of fulfilment.[24] Galan et al.,[14] also identified that the satisfaction with breastfeeding after CS was significantly higher (P ≤ 0.001) amongst those who initiated breastfeeding early and they also rated their breastfeeding experience as very good. A pilot study in which both the mother and the newborn were kept together after CS revealed that the patient satisfaction score was high as this intervention improved the maternal-infant contact. This intervention also improved the time taken for initiation of breastfeeding.[25] Breastfeeding experience is seen as fulfilling experience if imitated early probably due to the feeling of success in achieving this task which is considered as vital to motherhood.

Limitations

All women who met the inclusion criteria could not be included in the study as only one sample was observed at a time. This study was also conducted in a single centre therefore more representation from different setting in future studies may help in generalising the findings.


  Conclusion Top


Early initiation of breastfeeding proved to be effective in improving the breastfeeding behaviour of the newborns born by CS and the maternal satisfaction regarding initiation of breastfeeding was higher in the group with early initiation. Breastmilk is the lifeline for a newborn and therefore enhancing early initiation of breast feeding is an important aspect of midwives and nurses who look after women during delivery and child birth. Moreover, adequate breastfeeding support must be rendered in the recovery room of the operation theatre to the mothers undergoing CS as a part of routine health service provision.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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24.
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    Figures

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    Tables

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