Keywords

Breastfeeding, Cesarean, Infant care, Nurses.

 

Authors

  1. Hung, Kristina J. MS, RN, CNS
  2. Berg, Ocean MSN, RN, CNS

Abstract

This article describes a quality improvement project in which early skin-to-skin (STS) contact, in the operating room (OR) and during recovery, was used as an intervention to increase the success of breastfeeding initiation among healthy infants after cesarean, at a large, urban, acute care teaching hospital. The nursing role is key for the intervention, but the program involves the entire perinatal team, including the obstetricians, pediatricians, and anesthesiologists. During the first 3 months of our intervention, the rate of early STS among healthy babies born by cesarean increased from 20% to 68%. The rate of infants who did not get STS contact within 4 hours of birth decreased from 40% to 9%. Nine months after the initiation of the intervention, 60% of healthy cesarean births utilized STS in the OR, and 70% involved STS within 90 minutes of birth. Healthy infants born by cesarean who experienced STS in the OR had lower rates of formula supplementation in the hospital (33%), compared to infants who experienced STS within 90 minutes but not in the OR (42%), and those who did not experience STS in the first 90 minutes of life (74%). We concluded that STS contact was feasible after cesarean and could be provided for healthy mothers and infants immediately after cesarean birth. Perinatal and neonatal nurses should be leaders in changing practice to incorporate early STS contact into routine care after cesarean birth.

 

Article Content

Over the past few decades, the rate of cesarean births has increased significantly in the United States and around the world (Perez-Rios, Ramos-Valencia, & Ortiz, 2007). The Centers for Disease Control and Prevention (CDC) report a U.S. cesarean rate of 32% and a rate greater than 25% in 12 other industrialized countries (CDC, 2008; Menacker & Hamilton, 2010). Studies show that breastfeeding rates are lower among women who give birth by cesarean compared to women who give birth vaginally (Perez-Rios et al., 2007; Shawky & Abalkhail, 2003). This article describes a quality improvement project that aims to increase the rate of early skin-to-skin (STS) contact among healthy infants born by cesarean. The motivation driving this project was the desire to improve breastfeeding initiation after cesarean birth.

  
Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

Benefits of Breastfeeding

Evidence from the last three decades clearly suggests that breastfeeding benefits infants, mothers, and society. According to Chertok and Shoham-Vardi (2008), babies born by cesarean who are breastfed have lower rates of hospitalization during their first year compared to nonbreastfed babies. Benefits to the infant that have been associated with breastfeeding include lower risk of otitis media, gastrointestinal infection, necrotizing enterocolitis, lower respiratory tract infection, sudden infant death syndrome, asthma, allergies, childhood leukemia, obesity, and diabetes (Gartner et al., 2005; Ip, Chung, Raman, Trikalinos, & Lau, 2009). Maternal benefits from breastfeeding include lower rates of ovarian cancer, breast cancer, type 2 diabetes, as well as postpartum depression (Ip et al.). Bartick and Reinhold (2010) estimate that the United States would save $13 billion annually if 90% of infants were exclusively breastfed in the first 6 months of life, and that 911 lives would be saved.

 

Keys to successful breastfeeding include initiation within an hour of birth, frequent on demand feeds, maternal-infant STS contact soon after birth, and limiting maternal-infant separation (Miesnik & Reale, 2007; Mikiel-Kostyra, Mazur, & Wojdan-Godek, 2005). Early STS involves a naked infant lying prone on a mother's bare chest, with the infant's back covered by a blanket. This early contact is associated with successful initiation and greater duration of breastfeeding (Moore, Anderson, & Bergman, 2007). However, after a cesarean birth, mother and baby are monitored postoperatively for several hours, often in separate rooms and without the opportunity to breastfeed and bond.

 

Benefits of Skin-to-Skin

Ludington-Hoe and Swinth (1996), have suggested that early STS promotes neurobehavioral development and organization which correlates with improved breastfeeding behaviors (Ferber & Makhoul, 2004; Radzyminski, 2005). The results of a recent meta-analysis of randomized controlled trials published by the Cochrane Collaboration suggest that early STS contact has a positive effect on the success of the first breastfeeding, as well as breastfeeding status on postpartum day 3, at 1 to 4 months, and total breastfeeding duration (Moore et al., 2007). Additional benefits associated with early STS include infant temperature stabilization, less infant crying, higher infant blood glucose, and increased maternal satisfaction and confidence (Moore et al.). Although this quality improvement project focuses on healthy infants after cesarean birth, there is evidence that STS care benefits fragile, low-birthweight infants (Charpak et al., 2005). Bergman, Linley, and Fawcus (2004) report better cardiorespiratory stability and temperature outcomes among low-birthweight infants who experienced STS contact for the first 6 hours after birth compared to the infants placed in a servocontrolled incubator. Even though temperature stabilization is a key benefit of STS, in practice mothers and infants are often separated from each other because of the perceived need to put the infant under a warmer, and as a result are unable to initiate breastfeeding.

 

The practice of maternal-infant STS contact known as kangaroo care began in Colombia in 1978, and has since been used and studied around the world (Charpak et al., 2005). Chiu, Anderson, and Burkhammer (2008) demonstrated that STS contact can help lead to successful breastfeeding among a culturally diverse group of women in the United States. Thus, routine care in birthing environments should include the support of early mother-infant STS contact that occurs immediately after birth and lasts at least until after the first breastfeeding (Forster & McLachlan, 2007). Separation should not be part of routine care, even after a cesarean, as the mother can provide the ideal environment for successful newborn adaptation to the extrauterine environment. Further research that focuses on the effects of STS on infants born by cesarean would enhance our understanding of the intervention among this target population; however, the intervention has considerable benefits because STS contact requires minimal financial resources, is not associated with adverse effects among healthy infants, shows an overall positive effect on breastfeeding, and appears to improve newborn stabilization during transition.

 

Environmental Context

This quality improvement project used early STS contact in the operating room (OR) and during recovery to increase the rate of early STS among healthy infants born by cesarean. It took place at a large, urban, acute care teaching hospital in California. The hospital's birth center consists of a combined labor, birthing, and postpartum unit, with a separate level III nursery. The birth center has 1,300 births per year and a 20% cesarean birth rate, resulting in about 22 cesarean births per month. The birth center serves culturally diverse women and infants: 58% Hispanic, 13% African American, 12% Asian or Pacific Islander, and 6% White. Half of the women are single (neither married nor partnered), and the majority (88%) live at or below 150% of the federal poverty level. Breastfeeding support at the birth center is a high priority, as evidenced by its Baby-Friendly hospital accreditation. As a Baby-Friendly hospital it follows the Ten Steps for Successful Breastfeeding, developed by the World Health Organization (WHO) and the United Nation's Children Fund (UNICEF). However, infants born by cesarean had notably lower exclusive breastfeeding rates compared to infants who were born vaginally.

 

In accordance with the Rapid Cycle Improvement Process, as suggested by Healthcare Quality Strategies, Inc. (2003), the first author collected baseline data by doing a small sampling from the birth center. The sample results-which included only healthy, term infants born over a 2-week-period-showed over 90% of infants born vaginally were exclusively breastfed during their hospital stay (11 out of 12) compared to only 50% of infants born by cesarean (5 out of 10). Furthermore, only 20% of the cesarean infants were STS with their mothers within 90 minutes of birth, and 40% were not STS at all during the first 4 hours after birth. Of these infants who were not STS at all in the first 4 hours, 100% received formula supplementation while in the hospital. In contrast, of the infants born vaginally, only one did not get STS within the first 90 minutes of birth, and only this one infant got supplemented with formula.

 

Baby-Friendly recommends that mothers who give birth by cesarean be given their infants to hold in STS contact within 30 minutes of being able to respond, and notes that mothers who give birth by cesarean under regional anesthesia are generally able to respond to their infants immediately (WHO & UNICEF, 2009). Similarly, Gartner et al. (2005) and the American College of Obstetricians and Gynecologists (2007) recommend that mothers and healthy, term infants be placed in direct STS contact immediately after birth, and that separation be avoided as much as possible. However, at the birth center it takes about 75 minutes before a mother gets to the recovery room after a cesarean birth. This extended period in the OR is largely due to educational processes that take precedence in a teaching hospital. Due to this lengthy maternal-infant separation, we decided that our intervention should include the use of STS in the OR instead of simply beginning STS in the recovery room.

 

Staff Roles and Interrelationships

Standard care routines had hindered opportunities for STS and breastfeeding in the first 1 to 2 hours after cesarean birth in our institution. Labor nurses and nursery nurses share responsibilities for caring for mothers and their infants born by cesarean. The mother is cared for by a labor nurse who provides preoperative care, circulates in the OR during the cesarean, and helps the mother to recover in the postpartum room. Previously, a nursery nurse would care for the infant in the nursery until after the mother returned to the postpartum room for recovery, and lack of communication between the nursery nurse and the labor nurse lengthened the mother-infant separation. Furthermore, we hypothesized that women frequently go along with hospital routine and do not feel empowered to ask for their infants soon after cesarean birth when they have not had contact with them.

 

The birth center's Perinatal Clinical Nurse Specialist (CNS) identified the need to align postcesarean care with established Baby-Friendly principles by making systematic changes to minimize mother-infant separation and support early STS contact and breastfeeding initiation. Working in collaboration with the nursing staff and medical team, the Perinatal CNS and a Perinatal CNS student spearheaded the effort of implementing early STS contact after cesarean birth with the aim of increasing the success of breastfeeding initiation for these mother-infant pairs.

 

Implementation Process

The implementation process included the Plan-Do-Study-Act (PDSA Model for Improvement), which involves cycles of planning, doing, studying, and acting (Langley et al., 2009). We initially aimed to increase our rate of early STS (within the first 90 minutes of life) among all healthy, term infants born by cesarean to 60%.

 

PDSA Planning Phase

During the initial planning phase, we surveyed the nursing staff to gather ideas on the barriers and solutions to implementation, and to find the nurses interested in becoming champions of the improvement project. In addition, we visited the other Baby-Friendly hospital in the area-who had recently begun practicing STS in the OR-to gain practical insights. According to Rowe-Murray and Fisher (2002), early initiation of breastfeeding is possible regardless of the mode of birth if there is strong support of Baby-Friendly practices, effective interdepartmental communication, and participation by all staff. We reviewed the literature and consulted with key stakeholders including our Neonatal CNS, lactation consultant, as well as the anesthesia, obstetric (OB) and pediatric teams to address concerns and discuss ways in which OR procedures could be more conducive to safely implementing STS.

 

PDSA Doing Phase

We then drafted a flowchart to outline the team-based intervention process, which is displayed in Figure 1. The final decision regarding the appropriateness of STS in the OR is left to the discretion of the onsite pediatric and OB team, the anesthesiologist, as well as the nursery charge nurse after the newborn is initially assessed and dried. An infant is usually eligible for STS if they are considered vigorous with a strong respiratory effort (appropriate chest movement accompanied by an adequate depth and rate of respirations), a heart rate that is more than 100 beats per minute, pink lips and a pink trunk (without signs of central cyanosis), and good muscle tone (Goldsmith & Zaichkin, 2006).

  
Figure 1 - Click to enlarge in new windowFIGURE 1. Providing Skin-to-skin in the Operating Room

If the infant is eligible for STS in the OR, the nursery charge nurse supports STS for 15 minutes, or however long the mother is able and willing to do STS. The blue drape, which provides a barrier between the mother's upper body and the lower sterile field, is hung below the mother's breasts, allowing space for the infant to lie across the mother's upper chest. Thus, the nursery charge nurse assesses the spatial setup and I.V. placement, unties the mother's arms, lowers the mother's gown, places the naked infant transversely across the mother's bare chest covered by warm blankets, and places a cap on the infant's head.

 

PDSA Studying Phase

We initially piloted several cases with scheduled cesareans that involved healthy mothers and infants, and we modified our flowchart with feedback from the nurses. For example, we learned that (with the setup of our OR) the infant's head should lie toward the mother's right side so that the nurse can better monitor the infant. We rearranged some equipment in the OR (such as the suction canister) to allow for more space to support STS. Furthermore, in our original workflow, the nursery charge nurse called the nursery admit nurse to support STS in the OR, but it became evident that it was more efficient and effective for the nursery charge nurse to support STS before taking the baby to the nursery. As we expanded the project, we collected data to measure our progress. The results of the data collection can be found in the results section of this article.

 

PDSA Action Phase

For the first few cases, the Perinatal CNS remained in the OR and assisted the nursery nurse in positioning the infant. We then offered in-service education to the nursing staff and pediatric residents and posted a bulletin board presentation in the birth center and the nursery that was visible to both staff and patients. We also distributed the flowchart (Figure 1) to the staff and posted it in the OR. At this point, we encouraged all staff members to participate in implementing the intervention, and continued collecting data to monitor our improvement. We kept staff up-to-date on our progress by posting result data and patient feedback.

 

Quality Improvement Results

We collected data on all healthy infants born by cesarean. We focused on the timing of STS initiation, Latch, Audible swallowing, Type of nipple, Comfort, Hold (LATCH) scores, and the use of formula supplementation. All of these data were already routinely recorded by the nurses in the infant charts, which was essential to the feasibility of our assessment plan. Although there are various breastfeeding assessment tools in the literature, we used the LATCH tool because it was already being used in the birth center and is considered to be a reliable and effective tool to assess breastfeeding (Adams & Hewell, 1997). The duration of STS in the OR ranged from a few minutes to over 30 minutes, but was regarded as equal for data collection purposes.

 

It is important to note that the following data results are not meant to show associations between STS and breastfeeding, but rather to track the progress of this quality improvement project. During the first 3 months after implementation, the rate of STS within 90 minutes from healthy cesarean birth increased from 20% to 68%, and the rate of infants who did not get any STS contact within 4 hours decreased from 40% to 9% (Figure 2). Nine months later, 60% of healthy infants born by cesarean were STS in the OR, and 70% were STS within 90 minutes of birth. A compilation of data during the 9 months following the intervention shows a higher average in-hospital LATCH score among infants who experienced STS in the OR (8.0) compared to infants who did not get STS within 90 minutes (7.7) or within 4 hours (7.6). Furthermore, healthy infants born by cesarean who experienced STS in the OR had lower rates of formula supplementation in the hospital (33%), compared to infants who experienced STS within 90 minutes but not in the OR (42%), and those who did not experience STS in the first 90 minutes of life (74%).

  
Figure 2 - Click to enlarge in new windowFIGURE 2. Comparison of Skin-to-Skin Contact Rates After Cesarean Birth

Patient Feedback

We received positive feedback regarding mothers' experience with STS in the OR. Mothers stated that they would like to have STS contact with their babies in the OR if they were to experience a cesarean again, and commonly concluded that STS in the OR made them feel happy. One woman, when asked how she felt about having her baby STS with her in the OR, responded (translated from Spanish): I felt some pain at the end of the surgery because the effects of the anesthesia were wearing off, but when they put the baby in my arms I forgot about the pain because I was so happy to have him with me. She denied feeling worried about holding her baby STS in the OR and stated: With my last child they took her to the nursery right away [after the cesarean] and she never wanted to latch after that ... but this baby latched right away and he nurses really well because I had him with me right away. Another Spanish-speaking mother shared about her STS in the OR experience: It was nice, feeling her skin on me ... She was looking at me with her eyes wide open ... and I think we both could feel the attraction.

 

Challenges with Implementation

As with any change in practice, staff can be skeptical, reluctant, or fearful of change. We received positive responses after staff received the in-service education on benefits of STS and understood the need for improvement; however, we were unable to provide the in-service education to all of the staff. Another challenge was staff assignments. At our facility nursery nurses often have mixed assignments (both well and sick infants), so if a nurse is caring for a sick infant and is assigned to admit a healthy infant after cesarean, the nurse may not be able to leave the sick infant even for 15 minutes to support STS in the OR. As a result, the charge nurse now stays in the OR to support STS instead of the nursery admit nurse. Charge nurses and nurse managers can play a strategic role in working out appropriate staffing models.

 

Clinical Implications

Effective communication is essential to the success of this intervention. Communication regarding STS should begin preoperatively between the nurses, the patient, and the medical team, so that the entire team is aware of the possibility of STS in the OR. In addition, we hope that as the mother begins bonding with her infant in the OR, and having been taught the benefits of STS is more likely to ask for her infant to be brought to her soon after she arrives in the recovery room, where STS can continue in an unhurried and uninterrupted manner.

 

The experience of cesarean birth can be frightening or stressful to a mother who is strapped to the operating table, and is unable to watch her baby enter the world (WHO & UNICEF, 2009). Providing her with the opportunity to hold her infant in STS contact soon after birth can provide a sense of control and empowerment to the mother. With early STS contact, the nurse does not instruct the mother how to feed her infant or grab the mother's breast and put it into the infant's mouth. Instead the focus is on the mother's ability to provide the perfect environment and stimulation for the infant's reflexes and self-regulation to come into play, which in turn leads to successful breastfeeding initiation (Radzyminski, 2005). Parenting skills are strengthened as the mother provides appropriate caregiving by merely holding the infant, and in turn, the neurobehavioral development of the infant is promoted (Ludington-Hoe & Swinth, 1996).

 

Early STS maternal-infant contact has become the standard after vaginal birth, and there is no evidence that suggests that it should not be extended to cesareans. The Baby-Friendly Hospital Initiative suggests that STS contact should be provided for every healthy mother and infant immediately after birth, or as soon as possible during the first 30 minutes (WHO & UNICEF, 2009). Moore et al. (2007) did not find any negative outcomes from early maternal-infant STS contact in a meta-analysis that reviewed 30 randomized-controlled trials involving 1925 mother-infant pairs, including infants born by cesarean. In contrast, there is evidence that the lack of early STS may be harmful. Bystrova et al. (2009) found that mother-infant separation during the first 2 hours after birth is associated with less infant self-regulation, and decreased maternal sensitivity and attachment that is not compensated by rooming-in.

 

A critical role for nurses is to advocate for patients and families in situations where breastfeeding practices are not evidence-based, such as after cesarean births. Although research suggests that early STS contact is key to successful breastfeeding initiation, its use immediately after healthy cesarean birth is rare. Our experience shows that it is feasible to improve the quality of care after cesarean birth in a relatively short period. Nurses can be leaders in changing practice to incorporate early STS contact into regular cesarean care for mothers and infants by ensuring that the routine care after cesarean births is family-centered and research-based.

 

Nurses Who Work With Childbearing Women Should Know That:

 

* Early STS improves breastfeeding and supports infant temperature stabilization and neurobehavioral development.

 

* Early STS increases maternal confidence and satisfaction.

 

* Early STS should be provided for every healthy mother and infant immediately after birth, or as soon as possible during the first 30 minutes.

 

References

 

Adams, D., & Hewell, S. (1997). Maternal and professional assessment of breastfeeding. Journal of Human Lactation, 13, 279-283. doi:10.1177/089033449701300412 [Context Link]

 

American College of Obstetricians and Gynecologists, Committee on Health Care for Underserved Women, & Committee on Obstetric Practice. (2007). Breastfeeding: Maternal and infant aspects. ACOG Clinical Review, 12, 1S-16S. Retrieved from http://www.acog.org[Context Link]

 

Bartick, M., & Reinhold, A. (2010). The burden of suboptimal breastfeeding in the United States: A pediatric cost analysis. Pediatrics, 125, e1048-e1056. doi:10.1542/peds.2009-1616. [Context Link]

 

Bergman, N. J., Linley, L. L., & Fawcus, S. R. (2004). Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200- to 2199-gram newborns. Acta Paediatrica, 93, 779-785. doi:10.1080/08035250410028534 [Context Link]

 

Bystrova, K., Ivanova, V., Edhborg, M., Matthiesen, A.-S., Ransjo-Arvidson, A.-B., Mukhamedrakhimov, R., ..., Widstrom, A.-M. (2009). Early contact versus separation: Effects on mother-infant interaction one year later. Birth, 36, 97-109. doi:10.1111/j.1523-536X.2009.00307.x [Context Link]

 

Centers for Disease Control and Prevention. (2008). Quick stats: Rates of cesarean deliveries-selected countries. Morbidity and Mortality Report, 57, 1019. Retrieved from http://www.cdc.gov/mmwr/[Context Link]

 

Charpak, N., Ruiz, J. G., Zupan, J., Cattaneo, A., Figueroa, Z., Tessier, R., ..., Worku, B. (2005). Kangaroo mother care: 25 years after. Acta Paediatrica, 94, 514-522. doi:10.1080/08035250510027381 [Context Link]

 

Chertok, I. R., & Shoham-Vardi, I. (2008). Infant hospitalization and breastfeeding post-caesarean section. British Journal of Nursing, 17(12), 786-791. [Context Link]

 

Chiu, S. H., Anderson, G. C., & Burkhammer, M. D. (2008). Skin-to-skin contact for culturally diverse women having breastfeeding difficulties during early postpartum. Breastfeeding Medicine, 3, 231-237. doi:10.1089/bfm.2008.0111 [Context Link]

 

Ferber, S. G., & Makhoul, I. R. (2004). The effect of skin-to-skin contact (kangaroo care) shortly after birth on the neurobehavioral responses of the term newborn: A randomized, controlled trial. Pediatrics, 113, 858-865. doi:10.1542/peds.113.4.858 [Context Link]

 

Forster, D. A., & McLachlan, H. L. (2007). Breastfeeding initiation and birth setting practices: A review of the literature. Journal of Midwifery and Women's Health, 52, 273-280. doi:10.1016/j.jmwh.2006.12.016 [Context Link]

 

Gartner, L. M., Morton, J., Lawrence, R. A., Naylor, A. J., O'Hare, D., Schanler, R. J., ..., American Academy of Pediatrics. (2005). Policy statement: Breastfeeding and the use of human milk. Pediatrics, 115, 496-506. doi:10.1542/peds.2004-2491 [Context Link]

 

Goldsmith, J. P., & Zaichkin, J. (2006). Textbook of neonatal resuscitation: NRP slide presentation kit. Elk Grove Village: American Academy of Pediatrics. [Context Link]

 

Healthcare Quality Strategies, Inc. (2003). Multi-topic collaborative: Rapid cycle improvement process information. In Hospital Quality Initiative. Retrieved from http://www.esrdnetwork.org/assets/pdf/qi/rapid-cycleimprovement.pdf

 

Ip, S., Chung, M., Raman, G., Trikalinos, T. A., & Lau, J. (2009). A summary of the agency for healthcare research and quality's evidence report on breastfeeding in developed countries. Breastfeeding Medicine, 4, S17-S30. doi:10.1089/bfm.2009.0050 [Context Link]

 

Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed). San Francisco, CA: Jossey-Bass. [Context Link]

 

Ludington-Hoe, S. M., & Swinth, J. Y. (1996). Development aspects of kangaroo care. Journal of Obstetric, Gynecologic & Neonatal Nursing, 25, 691-703. doi:10.1111/j.1552-6909.1996.tb01483.x [Context Link]

 

Menacker, F., & Hamilton, B. E. (2010, March). Recent trends in cesarean delivery in the United States (NCHS Data Brief No. 35). Hyattsville, MD: National Center for Health Statistics. [Context Link]

 

Miesnik, S. R., & Reale, B. J. (2007). A review of issues surrounding medically elective cesarean delivery. Journal of Obstetric, Gynecologic & Neonatal Nursing, 36, 605-615. doi:10.1111/j.1552-6909.2007.00196.x [Context Link]

 

Mikiel-Kostyra, K., Mazur, J., & Wojdan-Godek, E. (2005). Factors affecting exclusive breastfeeding in Poland: Cross-sectional survey of population-based samples. Soz Praventivmed, 50, 52-59. doi:10.1007/s00038-004-3142-7 [Context Link]

 

Moore, E. R., Anderson, G. C., & Bergman, N. (2007). Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews, (3), CD003519. doi:10.1002/14651858.CD003519.pub2 [Context Link]

 

Perez-Rios, N., Ramos-Valencia, G., & Ortiz, A. P. (2007). Cesarean delivery as a barrier for breastfeeding initiation: The Puerto Rican experience. Journal of Human Lactation, 24, 293-302. doi:10.1177/0890334408316078 [Context Link]

 

Radzyminski, S. (2005) Neurobehavioral functioning and breastfeeding behavior in the newborn. Journal of Obstetric, Gynecologic & Neonatal Nursing, 34, 335-341. doi:10.1177/0884217505276283 [Context Link]

 

Rowe-Murray, H. J., & Fisher, J. R. (2002). Baby friendly hospital practices: Cesarean section is a persistent barrier to early initiation of breastfeeding. Birth, 29, 124-131. doi:10.1046/j.1523-536X.2002.00172.x [Context Link]

 

Shawky, S., & Abalkhail, B. A. (2003). Maternal factors associated with the duration of breast feeding in Jeddah, Saudi Arabia. Paediatric and Perinatal Epidemiology, 17, 91-96. doi:10.1046/j.1365-3016.2003.00468.x [Context Link]

 

World Health Organization, & UNICEF. (2009). BFHI Section 3: Breastfeeding promotion and support in a baby-friendly hospital. Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care. Retrieved from http://www.who.int[Context Link]