Influential Factors of Mother-Infant Skin-to-Skin Contact Based on the Precede-Proceed Model from the Perspective of Midwives in Torbat Heydariyeh Hospitals

Introduction

The first hours of life are the ideal time for establishing the primary interactions between the parents and neonate (1). Skin-to-skin contact, which occurs within the first hours after birth, prepares both the mother and neonate for a bilateral interaction (2). Furthermore, this method increases the ability of the mother in infant care enhancing her self-confidence and sense of attachment (3).

Mother-infant skin-to-skin contact was first proposed by Rey and Martinez 30 years ago in Bogotá (Colombia) as a technique to compensate for lack of national resources in hospitals providing care for neonates with low birth weight (4-6). This method was first implemented in South America, Europe and the United States; ever since, it has been used to rectify the complications in infants kept in incubators in developing countries (7, 8). For skin-to-skin contact, the naked belly of the infant is placed on the skin between the mother's breasts within the first minutes after birth (9).

According to the literature, skin-to-skin contact increases the body temperature of infants more effectively compared to an incubator. Moreover, it improves the respiration and restful sleep of neonates (5). Skin-to-skin contact is also associated with the reduction of neonatal mortality rate, pain, anxiety, infections and length of hospital stay, as well as increased maternal satisfaction, longer breastfeeding, and better emotional communication between the mother and infant (10-17).

Skin-to-skin contact not only regulates the autonomic nervous system and psychological complications in neonates, but it also positively affects the psychological state of the mother and infant in the future (18-20). The fourth step of the Baby-Friendly Hospital Initiative emphasizes the importance of skin-to-skin contact between the mother and infant immediately after birth, as well as the initiation of breastfeeding within the first hour of birth. However, mother-infant skin-to-skin contact is not yet performed appropriately in our country (21). In addition to promoting of breastfeeding, midwives are expected to support mothers in establishing skin-to-skin contact with the infant immediately after birth (22, 23).

Midwifery is a key profession in the promotion of family and community health. As we know, midwives play a major role in the process of childbirth. According to statistics, 54.45% of deliveries (48.6% in urban areas, 64.32% in rural areas) are carried out by midwives, and these health care professionals are the first ones to make contact with infants after birth. However, evidence suggests that despite the emphasis of the Ministry of Health on the implementation of mother-infant skin-to-skin contact immediately after birth, the majority of midwives refuse to perform this health behavior (21).

In one study, Nahidi et al. (2013) reported that the majority of midwives had adequate knowledge and favorable attitude towards the importance of skin-to-skin contact (24), while in another study, the same author stated that 90% of midwives refused to implement mother-infant skin-to-skin contact immediately after birth (21). Therefore, recognition of the obstacles against the establishment of skin-to-skin contact upon birth is of paramount importance. In this regard, behavioral analysis based on standard models often leads to an extensive understanding of the related influential factors. Available theories and models provide specific processes for the analysis of success or failure in performing medical procedures (25).

The Precede-Proceed model is a highly recommended pattern, which was later promoted to the Precede-Proceed model. This model is widely used to determine the behavioral factors involved in health care procedures (26). The Precede-Proceed model provides a framework in which behavioral risk factors, reinforcing factors, and enabling factors are evaluated separately (27).

In general, predisposing factors are defined as the parameters that form basic behavioral motivations. Such examples are information, attitude, beliefs, values, culture, customs and traditions, and some demographic features, which facilitate or inhibit a certain behavior.

Enabling factors facilitate or inhibit environmental and behavioral changes that affect the behaviors of an individual. Some of the parameters in relation to enabling factors are laws, health care plans, professional skills, and access to medical services and necessary resources.

Reinforcing factors are defined as the feedback received from others following a certain behavioral compatibility, which could promote or undermine the continuity of a behavior. Reinforcing factors include social support, peer groups, family members, individual abilities, health care providers, leaders, and respectable people for an individual (21, 25, 28). Identification and modification of these factors in educational programs could significantly influence the change or development of a behavior.

In medical training programs, the aforementioned factors should be considered and prioritized in order to focus on the effectiveness of each item during the early stages of an intervention. Predisposing, enabling and reinforcing factors could affect the behavior of midwives in establishing mother-infant skin-to-skin contact upon birth. For instance, in the study by Nahidi et al. (2014), the majority of midwives working in the hospitals of Tehran city (Iran) were aware of the key role of factors such as adequate equipment, human resources, and structured programs in the proper implementation of mother-infant skin-to-skin contact (29).

To date, few studies have been performed to evaluate the role of predisposing, reinforcing and enabling factors in the establishment of mother-infant skin-to-skin contact. Considering the differences in the individual, organizational and environmental conditions of the Iranian hospitals and medical centers, this study aimed to determine the influential factors for the proper implementation of mother-infant skin-to-skin contact immediately after birth based on the Precede-Proceed model from the perspective of the midwives in Torbat Heydariyeh hospitals..

 Materials and Methods

This descriptive cross-sectional study was conducted on 50 midwives working in the hospitals of Torbat Heydariyeh city, Iran in 2015. Due to the limitations of the study population, census sampling was performed on the midwives engaged in the maternity wards of 9^th.Dey and Razi hospitals affiliated to the Social Security Office of Torbat Heydariyeh city. Participants with informed consent were enrolled in the study, and those with incomplete questionnaires were excluded from the study.

Demographic data of the participants were collected, and the Mother-Newborn Skin-To-Skin Contact Questionnaire was also completed by the midwives. Demographic data were age, gender, marital status, employment status, work experience, interest in midwifery, job satisfaction, parity, gravidity, and training experience on skin-to-skin contact upon birth. Moreover, the demographic questionnaire included one open-ended question to assess the technique the midwives used to place the infant on the mother for skin-to-skin contact.

Mother-Newborn Skin-To-Skin Contact Questionnaire consisted of 53 items, which were scored based on a three-point Likert scale (Disagree=0, Do Not Know=1, Agree=2). This questionnaire has been extracted from three articles published by Nahidi and Tavafian. This scale evaluates the influential factors for skin-to-skin contact behavior in three areas of predisposing, enabling and reinforcing factors. Predisposing factors are divided into three subscales of attitude (11 items), barriers against performing skin-to-skin contact (five items), and perceived self-efficacy regarding the establishment of skin-to-skin contact (seven items) (21).

In Mother-Newborn Skin-To-Skin Contact Questionnaire, enabling factors include two subscales of social support (10 items) and motivation (seven items) in performing skin-to-skin contact (30). Social support is evaluated through the following parameters: 1) support from medical team members (e.g., obstetricians, anesthesiologists, pediatricians, colleagues, and hospital authorities) and 2) support and confidence of the parturient, her husband and family members in implementing skin-to-skin contact. As for motivation, it is evaluated through factors such as the knowledge of midwives and their willingness to establish skin-to-skin contact, maternal knowledge and satisfaction, and comfort of the mother and infant during skin-to-skin contact.

With respect to reinforcing factors, three subscales were evaluated, as follows: 1) structured programs for implementing skin-to-skin contact (two items), 2) provision of medical services for the mother (seven items) and 3) available facilities and equipment (four items) (29).

Answers on all the subscales were scored based on a three-point Likert scale (Disagree=0, Do Not Know=1, Agree=2). Considering the different score range of the subscales, the score for each subscale was calculated out of 100. Scores were defined as low (0-33.33%), moderate (33.34-66.66%), and high (66.67-100%).

 Moreover, the subscale of attitude was divided into three levels of negative, neutral, and positive, and perceived self-efficacy was divided into three levels of poor, moderate, and high.

Content validity of each questionnaire was confirmed using a qualitative approach by a panel of experts, and reliability was determined using Cronbach's alpha coefficient of >0.7 for all the subscales.

The study protocol was approved by the Ethics Committee of Torbat Heydariyeh University of Medical Sciences. Objectives of the study were explained to the participants, and informed consent was obtained from all the midwives prior to the study.

For data collection, the questionnaires were completed by the participants half an hour before their working shifts at the maternity wards of the selected hospitals without researcher supervision within 20 minutes. The researchers would clarify any ambiguity in case the participants had any questions about the data collection tools. Data analysis was performed in SPSS V.21 using descriptive statistics, tables and graphs.

 Results

In total, 43 midwives completed the questionnaires in this study. Mean age of the participants was 30.97±6.83 years (age range: 23-56 years), and mean of work experience was 5.25±2.03 years (range: 5 months-26 years). Mean scores of interest in midwifery profession and job satisfaction were 6.73±2.76 and 5.69±2.67, respectively (score range: 0-10).

Regarding the establishment of mother-infant skin-to-skin contact, 87.71% of the participants stated that they often placed the infant indirectly on the abdomen of the mother immediately after birth using sterile drapes, and only 11% of the midwives performed skin-to-skin contact properly. In other cases, the infant would stay attached to a warmer system with no skin-to-skin contact after exit from the birth canal by the midwife or other personnel responsible for providing the appropriate condition for breastfeeding.

Evaluation of the views of the midwives regarding the influential factors for skin-to-skin contact indicated that 88.1% and 11.9% of the participants had positive and neutral attitudes towards the mental and physical benefits of skin-to-skin contact, respectively (Figure 1).

Mean score of perceived self-efficacy in implementing skin-to-skin contact was 89.45±15.79. In this regard, 90.5% and 9.5% of the midwives had high and moderate self-efficacy in performing skin-to-skin contact, respectively (Figure 2).

According to the information in Table 2, the majority of our participants believed that factors such as neonatal and maternal diseases, cesarean delivery, infant care after cesarean section, and maternal fatigue were major obstacles against the implementation of skin-to-skin contact.

In this study, viewpoints of the midwives regarding the reinforcing factors for the implementation of skin-to-skin contact were investigated in two categories of social support and motivation. According to the information in Figure 3, 90.5% of the midwives claimed that the social support provided by the treatment team, hospital administration, and the parturient and her family members played a pivotal role in the proper establishment of skin-to-skin contact. In this regard, 9.5% of the participants stated that social support had a moderate role in performing skin-to-skin contact. In addition, 87.5% of the midwives believed that motivation was an essential element in the appropriate implementation of skin-to-skin contact.

In this study, we also evaluated the opinions of midwives about the effect of enabling factors on the establishment of skin-to-skin contact. According to the results, 92.2% of the participants emphasized the pivotal role of large-scale training programs, 91.9% highlighted the importance of available services, and 90% pointed out the significance of adequate equipment for implementing skin-to-skin contact (Figure 4). None of the participants considered the role of the aforementioned variables to be insignificant.

 Discussion

Despite its numerous benefits, only a small percentage of midwives in the maternity wards of Torbat Heydariyeh hospitals performed mother-infant skin-to-skin contact immediately after birth, and the majority of these midwives only indirectly placed the infant on the abdomen of the mother using sterile drapes. Similarly, the findings of Vakilian et al. indicated that although skin-to-skin contact was performed in most hospitals, insufficient attention was paid

 to the quality and duration of this intervention (31). According to the results of the present study, predisposing factors had a more significant role in the proper establishment of skin-to-skin contact in the viewpoint of midwives compared to motivation and behavior changes (21, 28).