Clinical audit of skin-to-skin contact and initiation of breastfeeding after birth

Abstract

Despite the well-established benefits of mother–infant skin-to-skin contact, the absence of immediate postnatal skin-to-skin contact and the separation of mothers and newborns appear to remain common practices in hospitals. This study was conducted to perform a clinical audit of skin-to-skin contact and the initiation of breastfeeding following birth. This cross-sectional study was conducted on 53 employed midwives and 265 postpartum mothers in two hospitals (Imam Sajjad and Shahid Akbarabadi) in Tehran Province. A census sampling method was applied. Data collection instruments included a demographic questionnaire and the national guideline checklist. Data were gathered through observation and interviews. For data analysis, descriptive statistics as well as the Chi-square and Fisher’s exact tests were employed using SPSS (version 22). A significance level of less than 0.05 was considered in all analyses. The results showed that 69.8% of midwives had an acceptable level of awareness regarding the standards of the guideline for establishing immediate postnatal skin-to-skin contact and initiating breastfeeding within the first hour of birth. The educational performance of all midwives was deemed unsatisfactory. The practical performance of 84.9% of midwives, as observed, was reported as unacceptable, and midwives in Imam Sajjad Hospital demonstrated better practical performance compared to those in Shahid Akbarabadi Hospital (36.4% vs. 0%), which was statistically significant (P = 0.001). Furthermore, midwives’ awareness was more acceptable in the age groups of 35–39 years (87.5%) and 40 years and above (100%), and this difference was statistically significant (P = 0.014).

Supplementary Information

The online version contains supplementary material available at 10.1038/s41598-025-23854-7.

Introduction

The first minutes and hours after birth are a critical period for both mother and infant, during which any disruption may affect the infant’s long-term health and neonatal survival¹. One of the most critical care practices for healthy newborn infants is mother-infant skin-to-skin contact (SSC) immediately after birth². Immediate mother-infant skin-to-skin contact (SSC) is a key care practice that stabilizes cardiovascular function and blood glucose, promotes brain development, prolongs breastfeeding, prevents hypothermia, strengthens bonding, reduces crying, and facilitates the infant’s adaptation to extrauterine life^3–5.

The benefits of SSC for mothers include a positive birth experience, reduced stress and postpartum depression, improved postpartum health, enhanced caregiving ability, and stronger attachment to the infant⁶. Additionally, infant movements during SSC stimulate oxytocin release, which increases milk production and reduces postpartum hemorrhage, a leading cause of maternal mortality in developing countries⁷. SSC can also help women who undergo cesarean delivery feel more involved in the birth process, increasing their childbirth satisfaction⁸.

The World Health Organization (WHO), the United Nations International Children’s Emergency Fund (UNICEF), the Baby-Friendly Hospital Initiative, and the American Academy of Pediatrics recommend mother-infant SSC after birth¹. During skin-to-skin contact (SSC), the naked newborn (wearing only a diaper and possibly a hat) is placed on the mother’s abdomen or chest, and both are covered to prevent hypothermia. SSC should begin within 10 min of birth and ideally last for over 60 min ⁹.

Skin-to-skin contact (SSC) is recognized as a vital intervention in improving maternal and neonatal health; however, multiple factors can influence its successful implementation. Recent evidence indicates that variables such as emotional support (doula support), neonatal characteristics including birth weight and gestational age, maternal characteristics such as maternal age, and mothers’ participation in childbirth preparation classes can serve as important predictors of successful SSC¹⁰.

Breastfeeding serves as the first line of defense for infants against poverty, mortality, and disease and represents the most sustainable investment for their social, cognitive, and physical capabilities¹¹. Early initiation of breastfeeding provides an opportunity for the mother to immediately hold and nourish her newborn after birth, which fosters a sense of empowerment, control, and skill enhancement in maternal caregiving¹². It has been estimated that in 2017, approximately 78 million newborns had to wait for over an hour before being placed on their mother’s breast¹³. During a study conducted across 24 countries from three continents (Africa, Latin America, and Asia), the prevalence of breastfeeding within the first hour of birth varied among the countries. It ranged from approximately 17.7% (in Peru ) to 98.4% (in Angola), with an average of 57.6%¹⁴. In a study conducted by UNICEF, the prevalence of breastfeeding within the first hour of birth was reported to range from 14 to 95% across 128 countries, Although the average prevalence rate was 64%, half of the countries had rates below 50%, indicating a wide variation¹⁵.

In Iran, the extent of implementing SSC is determined based on annual national reports. Annual reports assessing the implementation of the guideline "Initiation of immediate SSC between mother and newborn and initiation of breastfeeding within the first hour of birth" are prepared in child-friendly hospitals through the completion of questionnaires by breastfeeding specialists from the health deputy of universities during face-to-face visits. These reports indicate that the national average for guideline implementation was 78% in 2018 and increased to 89% in 2019, reflecting a 12% increase. While, based on recorded data from childbirth up to two hours after birth in the Iman system (www.iman.gov.ir-Infant Health Department), the prevalence of SSC in term infants weighing more than 2500 g was 36.3% in 2020. The statistical differences in Iran likely stem from challenges in implementing, recording, monitoring, and evaluating the SSC program. For instance, the presence of a breastfeeding specialist during annual evaluations may introduce bias. The Iman system records only whether SSC occurred and if it lasted an hour or less, without details on the implementation process or breastfeeding initiation. These issues suggest that the guideline is not fully institutionalized in most hospitals. Barriers to implementing SSC include staff shortages, heavy workload, limited awareness, time constraints, difficulty assessing newborn eligibility, lack of support, absence of policies, and cultural norms¹⁶,¹⁷. Evaluating the practical performance of midwives, particularly identifying areas that require improvement, determining their educational needs, and ensuring the provision of quality care have paramount importance¹⁸.

Clinical audit is a key tool for improving healthcare quality. By systematically comparing midwifery care to established standards, it identifies strengths and weaknesses, enabling targeted interventions to enhance midwives’ performance¹⁹.

So far, no study has been conducted in Iran regarding the clinical audit of SSC between mother and newborn and the initiation of breastfeeding after birth using the standardized checklist provided by the Ministry of Health. Based on this, the present study was conducted with the aim of clinical auditing of SSC and initiation of breastfeeding after birth in selected hospitals affiliated with the Iranian Universities of Medical Sciences, with the checklist of the Ministry of Health²⁰ prepared according to the precise standards set by the WHO.

Methods

Study design and setting

The present research is a cross-sectional study that was conducted on all midwives working in the maternity wards and operating rooms of two teaching (Shahid Akbarabadi Hospital) and non-teaching hospitals (Imam Sajjad Hospital) in the city of Tehran (the capital of Iran). One of the classifications of hospitals is based on whether they are teaching or non-teaching hospitals. Teaching hospitals are among the most active types of hospitals. In addition to the staff, educational personnel such as residents, interns, students, and professors are present in these hospitals. In the present study, all the midwives of these two hospitals, who were involved in establishing skin-to-skin contact between mother and baby and breastfeeding in the first hour after delivery were included in the study. It should be noted that the average number of births in the teaching hospital was 6500 and in the non-teaching hospital was 3500 per year. The selection of the two hospitals was based on their high patient admission rates among the hospitals affiliated with Iran University of Medical Sciences.

In this study, a census sampling approach was employed, including all 53 midwives working in the two selected centers. The sample size encompassed the entire eligible population. Given the observational nature of the study, a formal power analysis was not deemed necessary. Furthermore, to enhance the reliability of the findings and minimize potential variability, each midwife was observed on five separate occasions, with data collected from five mother-infant dyads under their care. In total, samples comprised 53 midwives and 265 mothers. Sampling commenced in November 2020 and continued until March 2021. In this study, only mothers who had full-term, singleton, healthy infants and low-risk pregnancies with the ability to provide immediate newborn care were included. Exclusion criteria encompassed neonatal death, the need for resuscitation and transfer to the Neonatal Intensive Care Unit (NICU), and untreated conditions in the mother that hindered breastfeeding and SSC, such as active tuberculosis.

Data collection

Demographic questionnaire of midwiferies

It included age, marital status, educational level, employment status, years of service, and sampling shift (morning, afternoon, evening).

A checklist to assess immediate SSC after birth and initiation of breastfeeding within the first hour postpartum:

In this study, a checklist was used to evaluate the implementation of the guideline on establishing skin-to-skin contact between mother and newborn immediately after birth and initiating breastfeeding within the first hour, as reported annually across Iran²⁰. The checklist consists of four sections, organized into separate forms. A total score of 80% or higher on the forms is considered acceptable. Since the checklist is derived from the standard forms of the Ministry of Health and Medical Education, its validity and reliability have been confirmed.

The first section

Consisted of a question from the midwives regarding their completion of training courses within the past two years and the other ten questions aimed at assessing their awareness about implementing skin-to-skin contact and breastfeeding. The responses were recorded as “Yes” or “No”.

The second section

This section evaluated the educational performance of midwives. It comprised ten questions regarding adherence to the practices taught for implementing SSC and breastfeeding with the mother. The responses were recorded as “Yes” or “No” based on whether to give or not to give training.

The third section

This section assessed the practical performance of midwives. It consisted of fifteen questions observed and assessed during SSC and breastfeeding with the mother in the labor/delivery room or operating room. The responses were recorded as “Yes” or “No” based on whether the actions were performed or not performed.

The fourth section

The questions in this section are about interviews with postpartum mothers. It consisted of seven questions regarding the implementation of SSC and breastfeeding after a vaginal or cesarean delivery. The responses were recorded as “Yes” or “No” based on whether the practices were performed or not performed.

Observing the educational and practical performance of midwives

In the case of midwives, to avoid observation bias and respect ethical issues, they were informed that their function would be monitored without reference to the subject of the study. To normalize the observer’s presence and minimize behavior changes, the researcher spent several days in the department before sampling. The researcher subtly observed the performance of midwives. Interviews with midwives were conducted after the observation sampling to investigate their awareness and mothers to investigate the executive functioning of midwives from their point of view.

Ethical approval

This study was approved by the Ethics Committee of Iran University of Medical Sciences, Tehran, Iran (Number: R.IUMS.REC.1400.416). In addition, informed written consent was obtained from the participants. Participants were also assured of the confidentiality of their information.

Statistical analysis

The data were analyzed using SPSS, version 22.0. Following the Shapiro–Wilk test, the quantitative data were considered to be normally distributed. Descriptive statistics including frequencies and percentages, mean and standard deviation were used for describing individual characteristic variables, along with Checklist questions. To compare the clinical audit of awareness, educational performance and practical performance of midwives, chi-square and Fisher’s exact tests and t-tests were used. P values less than 0.05 were considered statistically significant.

Results

A total of 53 midwives were assessed for eligibility and were ultimately divided into two groups: a non-teaching hospital (22 midwives) and a teaching hospital (31 midwives). The age range of midwives was between 24 and 55 years with a mean and standard deviation of 33.27 ± 7.97. The service experience range of midwives was between one and 26 years with a mean and standard deviation of 13.48 ± 7.67. More information about the demographic characteristics of the studied midwives is presented in Table 1.

Table 1.

Sociodemographic characteristics of midwives (n = 53).

Variables		N (%)
Age	24–29	24 (45.3)
	30–34	10 (18.9)
	35–39	8 (15.1)
	≥ 40	11 (20.8)
Marital status	Single	10 (18.9)
	Married	43 (81.1)
Level of education	Bachelor’s degree	41 (77.4)
	Master’s degree	12 (22.6)
Employment status	Official	28 (52.8)
	Contractual	10 (18.9)
	Conscripted	15 (28.3)
Years of service	1–9	36 (67.9)
	10–19	8 (15.1)
	≥ 20	9 (17)
Sampling shift	Morning	18 (34)
	Evening	18 (34)
	Night	17 (32)

As Table 2 shows 30.2% of midwives had an unacceptable level of awareness. No statistically significant difference was observed between teaching Hospital and non-teaching hospital. Regarding the educational performance of midwives regarding SSC and breastfeeding immediately after delivery, the results indicated that none of them demonstrated an acceptable level of performance about the established guidelines for immediate SSC after birth and initiation of breastfeeding within the first hour postpartum. The educational function of all midwives (100%) was deemed unacceptable. For this reason, we did not have data to present for this variable in Table 2.

Table 2.

Clinical audit of awareness and practical performance among midwives (n = 53).

Variables	Hospital	Status		p-value
		Acceptable N (%)	Unacceptable N (%)
Awareness	Teaching Hospital	22 (71)	9 (29)	P* = 0.828
	Non-teaching hospital	15 (68.2)	7 (31.8)
	Total	37 (69.8)	16 (30.2)
Practical performance	Teaching Hospital	0 (0)	31 (100)	P** < 0.001
	Non-teaching hospital	8 (36.4)	14 (63.6)
	Total	8 (15.1)	45 (84.9)
Practical performance of midwives from the point of view of mothers	Teaching Hospital	0 (0)	31 (100)	P** = 0.025
	Non-teaching hospital	4 (18.2)	18 (81.8)
	Total	4 (7.5)	49 (92.5)

* Chi-Square** Fisher’s Exact.

In terms of practical performance, following the observation of 53 participating midwives (each midwife observed five times), it was found that only 15.1% of midwives had an acceptable level of practical performance according to the established guidelines for immediate SSC after birth and initiation of breastfeeding within the first hour postpartum. Furthermore, the clinical audit of midwives’ practical performance based on interviews with mothers showed that 7.5% demonstrated an acceptable level of performance.

As Table 3 shows, a significant correlation was observed between age and midwives’ awareness of SSC and initiation of breastfeeding after birth. So that, midwives in the age groups of 35–39 years (87.5%) and 40 years and above (100%) demonstrated higher levels of acceptable awareness. However, due to the unacceptable educational performance of all midwives was not possible to examine the relationship between educational executive functioning and sociodemographic variables. No statistically significant correlation was observed between sociodemographic variables and practical performance through observation. Similarly, no significant statistical relationship was observed between midwives’ practical performance, as assessed by mothers, and sociodemographic variables. The frequency distribution of items for each of the four sections of the checklist assessing immediate SSC after birth and initiation of breastfeeding within the first hour postpartum is presented in the Table S1.

Table 3.

Clinical audit of awareness and practical performance based on sociodemographic characteristics (n = 53).

Variables	Awareness	Practical performance	Practical performance of midwives from the point of view of mothers
	p-value
Age	p** = 0.014	p** = 0.132	p** = 0.213
Marital status	p** = 0.704	p** = 0.999	p** = 0.999
Level of education	p** = 0.999	p** = 0.361	p** = 0.563
Employment status	p** = 0.233	p** = 0.164	p** = 0.503
Years of service	p = 0.086	p** = 0.164	p** = 0.579
Sampling shift	p* = 0.102	p** = 0.500	p** = 0.450

*Chi-Square** Fisher’s Exact.

Discussion

The aim of the present study was the clinical audit of SSC and initiation of breastfeeding immediately after birth in selected hospitals affiliated with Iran University of Medical Sciences. Regarding midwives’ awareness of the guidelines for establishing immediate SSC and initiating breastfeeding within the first hour after birth, the results showed that among the 53 participating midwives, the majority (69.8%) demonstrated an acceptable level of awareness, while approximately one-third exhibited insufficient awareness. Furthermore, no significant difference was observed in the level of awareness between midwives in the two studied hospitals, teaching and non-teaching. The study by Dirirsa et al. showed that most employees (68.5%) had an acceptable level of awareness²¹. In this study, a score of 50% or higher was considered an acceptable level of awareness. In that study, a score of 50% or higher was considered acceptable. Similarly, studies by Engler et al. and Nahidi et al. indicated that most midwives are familiar with the definition of SSC, which is consistent with our findings^22,23. In line with the present study, Nahidi et al. also reported no significant difference in awareness levels between midwives working in teaching and non-teaching hospitals.

Regarding midwives’ educational performance, none demonstrated an acceptable level in relation to the guidelines for immediate SSC and initiation of breastfeeding within the first hour after birth. In fact, the educational performance of all midwives (100%) was considered unacceptable. Continuous education for healthcare workers, including maternal and neonatal health caregivers and midwives, along with appropriate support from the heads of labor and delivery units, can significantly enhance their motivation and educational performance²⁴.

Building on this, Mohammadi et al. demonstrated that passive transfer of information, while increasing awareness and awareness, does not necessarily lead to improved care performance. Therefore, attention to effective educational strategies that promote deep learning and behavioral change is essential for the future expansion and development of skin-to-skin contact^25,26. The results of Mukherjee et al.’s study revealed that the most common reason for not implementing SSC was a lack of maternal awareness (25.82%). This may be due to inadequate or insufficient training provided by midwives to mothers at the health center, which aligns with the findings of the present study²⁷. However, the results of the study by Caponero et al. were not consistent with those of the present study, as they reported that midwives’ educational performance was satisfactory. This discrepancy may be attributed to their use of standardized and consistent video-based training, which is not influenced by external factors²⁸. In this study, midwives may have overlooked breastfeeding and SSC education because they assumed that mothers had already been trained during pregnancy or had prior experience from earlier births.

Regarding the clinical audit of midwives’ practical performance, the findings indicated that the majority of midwives demonstrated unsatisfactory performance. Previous studies have highlighted the lack of protocols for postnatal care, as well as inadequate postnatal care practices following childbirth²⁹. Additionally, factors such as insufficient motivation and skill among healthcare providers in performing SSC, maternal reluctance, non-cooperation, staff shortages, heavy work shifts, and environmental culture have been identified as barriers to SSC implementation^30,31. Currently, SSC between mother and infant occurs in hospitals, but little attention is paid to the duration and quality of this contact^32,33. The WHO and UNICEF recommend 60 min of skin-to-skin contact and suggest that breastfeeding be initiated within 30 min after birth^34,35.

In Iran, since 2013, a national guideline titled "Initiating SSC and Breastfeeding within the First Hour of Birth" has been introduced, accompanied by an instructional guide for healthcare personnel on implementing the guideline. Educational pamphlets for various hospitals have been distributed to both healthcare personnel and mothers, and workshops on SSC and breastfeeding have been conducted for midwives³⁶. Therefore, these factors are considered facilitators rather than barriers to initiating skin-to-skin contact and breastfeeding within the first hour after birth. Shabanikordsholi reported that barriers to SSC include deficiencies in awareness and awareness, human resource limitations, environmental issues, content-related shortcomings in the guideline, maternal and newborn safety concerns, cultural factors, and managerial and supervisory problems³⁷. These findings are consistent with the results of the present study, as although all participating midwives had completed workshop courses and in-service training, their practical performance was unsatisfactory, which may be attributed to a lack of supervision.

The national average implementation of the guidelines in Iran was 78% in 2018 and 89% in 2019, but according to the IMAN system in 2020, only 36.3% of full-term infants over 2500g received skin-to-skin contact²⁰. These discrepancies likely stem from deficiencies in implementation, recording, monitoring, and evaluation, as well as potential assessor bias, indicating a possible institutional failure to enforce the guidelines in most hospitals and healthcare centers.

The results of a study showed that the highest rate of SSC implementation occurs in local hospitals³⁸. Similarly, in our study, SSC implementation was lower in the teaching hospital than in the non-teaching hospital. Overcrowding in educational hospitals and the insufficient number of personnel relative to the number of births may be one of the reasons for the poor executive functioning. In a study investigating barriers to SSC implementation in England, Rwanda, Zambia, and Saudi Arabia, it was found that training is crucial to support and improve implementation performance. The study noted that although SSC appears to be a simple practice, various obstacles may prevent it from being carried out as expected, such as the limited number of personnel both in the UK and internationally³⁹.

The results of another study demonstrated that one of the main barriers to the implementation of skin-to-skin contact and poor execution performance is the lack of protocols for postnatal implementation²⁹. However, in our study, although a protocol was in place, the practical performance by the majority of the staff was deemed unacceptable.

The results of the present study showed a significant association between age and midwives’ awareness. Midwives aged 35–39 years and those 40 years and above demonstrated higher levels of awareness. Since the educational performance of all midwives regarding SSC guidelines and breastfeeding initiation after birth was deemed unacceptable, the relationship between educational performance and demographic variables could not be examined. Furthermore, no significant associations were observed between demographic variables and the practice of SSC or breastfeeding initiation. Similarly, there was no significant correlation between midwives’ execution performance according to guideline standards and demographic characteristics. In line with our results, Almutairi et al. also revealed no association between years of service and the implementation of SSC⁴⁰. Deng et al. showed that nurses’ experience, role in the NICU, and, to a lesser extent, higher levels of education influenced their awareness, perceptions, and practice of kangaroo care, which partially contradicts the findings of the present study⁴¹.

The main strength of this study was the inclusion of midwives from two different centers with high childbirth rates in Tehran. Clinical audits were conducted using standardized checklists. However, several limitations should be noted. First, the study used a “census sampling” method without randomization, which limits the generalizability of the findings. Second, only government hospitals were included, so the results may not represent midwives in the private sector or the broader community. Third, the presence of the researcher during assessments could have introduced observer bias (Hawthorne effect). To minimize this, the researcher spent several days in the ward prior to data collection to normalize their presence. Additionally, questionnaires for midwives were administered when they were willing, not fatigued, and had manageable workloads, and mothers completed questionnaires within the first 24 h after birth in a consistent environment to ensure equal conditions. Finally, the study did not examine whether the service provider was a parent, which may influence the effectiveness of breastfeeding support or skin-to-skin contact.

Despite midwives having a reasonable level of awareness regarding the guidelines for immediate SSC after birth and initiation of breastfeeding within the first hour, their educational and practical performance was not favorable. It is necessary to monitor the educational and practical performance of breastfeeding and SSC.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

SSC

Skin-to-skin contact

WHO

World Health Organization

UNICEF

United Nations International Children’s Emergency Fund

NICU

Neonatal Intensive Care Unit

USIKC

United States Institute for Kangaroo Care

Author contributions

All the authors have contributed to the conception and design of the study, drafting the article or revising it, and approving the version to be submitted. Data collection was performed by R.A. Data analysis and interpretation were performed by R.A., SS.M., SB.H., and A.B. Moreover, R.A., SS.M., Z.D., and SB.H. wrote and revised the paper. All the authors read and approved the final manuscript.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Competing interests

The authors declare that they have no competing interests.

Ethics approval and consent to participate

The Ethics Committee of Iran University of Medical Sciences, Tehran, Iran (Number: IR.IUMS.REC.1400.416) approved the study protocol. The purpose and procedures of the study were fully informed to the participants. Then informed written consent was obtained from them (midwives and mothers). In addition to the verbal explanation, the written informed consent signed by the mother specified that, with the mother’s written permission, skin-to-skin contact and breastfeeding of the infant would be observed by a midwife researcher during the first hour after birth. Given the study’s purpose, which required no intervention on the infant and solely involved observing skin-to-skin contact and breastfeeding, mothers considered their written consent sufficient and did not consider the need for consent from the father to be necessary. Participants were also assured of the confidentiality of their information. All methods were carried out in accordance with our study protocol, along with relevant guidelines and regulations associated with the Iran University of Medical Sciences and professional regulatory bodies such as the Nursing and Midwifery Council.

Consent for publication

Not applicable.