http://doi.org/10.33698/NRF0125- Himani ,Baljit Kaur ,Praveen Kumar
Abstract : Breast feeding is the feeding of an infant or young child with breast milk directly from human breasts. Studies have been carried out on a number of variables e.g. health benefits of breast feeding for neonate and mother. Maternal- infant bonding is one of the variables which is least studied. The present study was undertaken to assess the effect of initiation of breast feeding within one hour of the delivery on maternal- infant bonding. Two hundred and eighteen mother- infant dyads were enrolled for the study and considered for analysis. Each group (control and experimental) comprised of one hundred and nine mother-infant dyads. Mothers who initiated breast feeding after one hour of the delivery were considered in the control group and the mothers in the experimental group initiated breastfeeding within one hour of the delivery. Value of t at 24 hrs was -7.428 and at 48 hrs was -8.894. Significant difference p= 0.000 < 0.5 was found between the maternal infant bonding scores of control and experimental group at 24 as well as 48 hours of the delivery. At 24 hours of the delivery, mean ± S.D of score was found 73.6 ± 9.0 in the control group while the score was 81.1 ± 5.3 in the experimental group and at 48 hours it was 74.5 ± 8.9 in control group and 83.3 ± 5.3 in the experimental group. The result revealed that initiation of breast feeding within one hour of delivery improves maternal- infant bonding. So, it is recommended that breast feeding should be initiated within one hours of delivery.
Key words :
Breast feeding, Maternal- infant bonding, Mother- infant dyad.
Correspondence at :
Himani
Lecturer,
Sukhmani College of Nursing,
Dera Bassi, District: Patiala, Panjab.
Background
Breast feeding is as old as human kind. It is universally acknowledged to be the best and complete food for infants as it fulfills specific nutritional needs1. Extensive research in the recent years, documents diverse and compelling advantages of breast feeding to infants, mothers, families and society. These also include nutritional, immunological, developmental, psychological, social, economic and environmental benefits.2,3,4 Hospital team can have a significant impact on the initiation and maintenance of breast feeding, if they have sufficient knowledge of its benefits and the necessary clinical management skills or habits.5 In order to ensure success in breast feeding, it is impor tant that it be initiated as early as possible during the neonatal period.6 Right after birth the sucking reflex is most active and babies are more alert during the first 30- 60 minutes and if babies are put to mother’s breast within this period, chances of exclusive breast feeding increase.6
Early initiation of breast feeding enhances “Maternal- infant Bonding”.6“ Maternal-Infant bonding” means the development of the core relationship between mother and child.7 The bonding process occurs in both infant and mother and has tremendous implications for the child’s future development.7 “Maternal infant bonding is a vital process which begins in early infancy and continues over the next few years. The bonding process has tremendous implications for both mother and child and is affected by many factors.”7Many studies have addressed the question of whether there is what has been called a ‘sensitive period’ for parent- child contact in the first minutes, hours and days of life that may alter the parent’s behaviors with their infant later in the life.8 In each study, increasing the mother- infant time together or increased suckling improves caretaking by the mother.8
Salariya et all also found that babies who were first fed within 30 minutes of birth were likely to remain breast feeding for longer.9 The relationship between early first contact of mother and infant and outcome of breastfeeding may be closely related to what Klaus and Kennell (1976) describe as an early sensitive period in the mother. This immediate postpartum period seems to be the time for optimum attachment or bonding of the mother to the infant.9
A 1974 study at Brazil compared the breastfeeding of two groups of 100 women. The mothers of one group nursed their infants immediately after bir th and maintained permanent contact throughout the hospital stay with their infants in cribs by their beds. The control group mothers had a glimpse of their infants shortly after birth and then visits for approximately 30 minutes, every 3 hours, 7 times a day, beginning 12-14 hours after birth. At 2 months, 77% of the experimental group mothers were breastfeeding without supplemental formula. In contrast, only 27% of the control group mothers were breastfeeding without formula supplements at 2 months. Knowledge and support must also be considered causal factors in this study as a special nurse worked with the mothers of the experimental group to stimulate and encourage breastfeeding.10
Salaryia et al (1978) assigned 111 primiparous women intended to breastfeed into groups matched for age and social class. Half of the subjects had their infants put to the breast within 10 minutes after birth. The other subjects began breastfeeding at four to six hours after delivery. The early-initiation group fed for an average of 161 days or about 40% longer than the 96 day average in the other group. Each of these early contact studies supported the idea of a maternal sensitive period in the first hour after birth. Prolonged breastfeeding appears to be one of the outcomes of promoting early contact of mother-infant pairs.11
Breast feeding provides considerable health benefits for mothers, babies and economic benefits to the healthcare system.12 Long term success and sustainability requires a shift in attitude of both the public and health professionals towards breast feeding. It is a natural act but not necessarily an easy one to initiate.13,14,15 Enthusiastic suppor t and involvement of health team in promotion and practice of early initiation of breast feeding is considered essential to achieve optimal health, growth and development of new born baby as well as mother and to improve “maternal- infant bonding” . Factors that affect the intention, initiation and duration of breast feeding are complex and therefore to address these factors, specialized approach is required.16 Hospital policies and routines greatly influence breastfeeding success. The peri-par tum hospital experience should include adequate support, instruction and care to ensure the successful early initiation of breastfeeding. Such management is part of a continuum of care and education begin during the pre-natal period that promotes breastfeeding as the optimal method of infant feeding and includes information about maternal and infant benefits.17
Though, it is important to initiate breast feeding to new born baby within 1 hour of delivery, yet no studies have been done so far in the Institute to see the effect of initiation of breast feeding within 1 hour of delivery on “maternal-infant bonding”. WHO recommends that breast feeding should be initiated within 1 hour of delivery. So, the need aroused to conduct the study and assess the effect of initiation of breast feeding within 1 hour of the delivery on “maternal-infant bonding” and produce research based evidence.
Objective of the study
To assess the effect of initiation of breast- feeding within 1 hour of delivery on “Maternal- Infant bonding”.
Material and Methods
The quasi- experimental study was conducted with the mothers and their new born babies in the Obstetric Unit, Nehru Hospital, PGIMER, Chandigarh in August- September 2009. PGIMER,Chandigarh is an autonomous institute. It was established in 1962 as a referral centre and ter tiary level institute This is one of the premier Institutes of the country for imparting medical, para- medical education and conducting research. Nehru Hospital with 1600 beds attached to the Institute, provides indoor health care facilities. The present study was conducted in the Obstetric Unit which consist of–Clean Labour Room (CLR), Maternity Ward and Gynecology Ward. Obstetric unit is situated on the third level. Clean labour room and Gynecology ward are in the ‘D’ block and Maternity Ward is in ‘B’ Block.
Purposive sampling technique was employed to select sample from the population. During first phase the mothers were contacted after one hour of the delivery and asked whether they have initiated breast feeding to their baby. If the breast feeding was not initiated within one hour of the delivery, mother- infant dyad was considered in the control group. And if breast feeding was initiated within one hour of the delivery, mother- infant dyad was considered in the experimental group. During the second phase, the mothers were contacted within one hour of the delivery and breast feeding was initiated within one hour of the delivery using the developed protocol i.e. mother- infant dyad were considered in the experimental group. Protocol for the initiation of breast feeding was developed by consulting the experts and review of the literature.
All the mothers with normal vaginal delivery (period of gestation 36 weeks and above) who were willing to participate in the study were considered eligible and included in the study except the mothers and new born babies in the exclusion criteria. The mothers having the problems i.e. Eclampsia, twin pregnancy, medical- surgical diseases which interfered with the initiation of breast feeding, post- partum haemorrhage and post- partum psychosis and the new born babies with the problems i.e., pre-term less than 36 weeks of gestation, birth weight less than 1.8 Kg, APGAR less than 7 at 1 and 5 minutes, congenital malformations which interfered with the breast feeding, babies shifted to Neonatal Intensive Care Unit (NICU), babies with medical- surgical problems where direct breast feeding is contraindicated were excluded from the study.
The research tools included 1) Protocol for the initiation of breast feeding, 2) Performa for sample collection and identification data sheet, 3) Tool to assess maternal- infant bonding. Tool to assess maternal- infant bonding included “Maternal Postnatal Attachment Scale (MPAS)” [Condon and Corkindale, 1998] which consisted of 19 questions. The Performa was modified as per the need of the study. Reliability of the tool was assessed by Cronbach’s alpha. Its value was 0.7998 at 24 hours and 0.8118 at 48 hours.
The experiment was carried out in two phases. During phase-I, the mothers were contacted after one hour of the delivery asked about the initiation of breast feeding. If the breast feeding was not initiated within one hour of the delivery, then the mother- infant dyad was considered in the control group but if the breast feeding was initiated within one hour of the delivery, then the mother- infant dyad was considered in the experimental group. Identification perform was filled at one hour. Performa for the assessment of “maternal- infant bonding” was filled at 24 and 48 hours of the delivery. During phase-II, the mothers were contacted within one hour of the delivery. Mother- infant dyads were considered in the experimental group. Breast feeding was initiated within one hour of the delivery using the developed protocol, Identification Performa was filled at one hour and the tool to assess “maternal- infant bonding” was implemented at 24 and 48 hours of the delivery.
Results
Two hundred and eighteen mother- infant dyads were enrolled for the study and considered for analysis. Each group (control and experimental) comprised of one hundred and nine mother-infant dyads. Analysis of gathered data was done using differential and inferential statistics.
Majority of the subjects were in the age group of 21-25 years. Age of the study subjects (mothers) in the control group ranged between 19 to 38 years. Mean age ± S.D was 26.2 ± 4.1. Whereas in experimental group the age of study subjects ranged between 20 to 41 years. Mean age ± S.D was 26.5 ±3.8. Per capita income of subjects ranged between Rs 201/- Rs 25000/- per month. Sixty- three (57.8%) subjects from group had per capita income of Rs 501- whereas fifty-one (46.8%), subjects from experimental groups had per capita income Rs 1000/- per month. In the control group, per capita income per month ranged between Rs 200/- to 25000/-, Mean ± S.D was 2867.6± 4475.7. On the other hand, in the experimental group, range was Rs 250/- to 25000/-, mean ± S.D was 4204.3± 5784.6. of the subjects were literate 36.7% subjects from experiment group and 55.1% from control group studied upto matriculation. Most of the subjects i.e. 77.9% from experimental group and 89.5% from control group were house wives. More than half (52.3%) of subjects from experiment group and 66.9% from control group were from rural background (Table 1).
In both the groups, more than half of the study subjects were multigravida i.e. 65.1% from control group and 56.9% from experimental group. More than 75% of study subjects delivered between 37+1 to 40 weeks period of gestation in both control and experimental groups. In control group, 12.8%, subjects delivered between 36 to 37 weeks, 76.2% delivered brtween 37+1 to 40 weeks and 11.0% had period of gestation of 40+1 weeks and above at the time of delivery. In experimental group too, 15.6% subjects delivered at period of gestation 36 to 37 weeks, 75.2% during 37+1 to 40 weeks and 10 (9.2%) at 40+1 weeks and above. In the control group, 48 (44.1%) subjects, had baby boy and 61 (55.9%) had baby girl while in experimental group, 57 (52.3%) subjects, had baby boy and 52 (47.7%) had baby girl. (Table-2)
The comparison of maternal- infant bonding was done at 24 and 48 hours of the delivery and the scores were compared. In control group, mean bonding score on maternal- infant attachment scale at 24 hours of the delivery ranged from 44.5- 89.2 with mean score 73.6 ± 9 and at 48 hours the score ranged from 44.5- 92.2 with mean ± S.D score 74.5 ± 8.9. In the experimental group, mean bonding score and range on maternal- infant attachment scale at 24 hours of the delivery between 62.4- 91.0 with mean score 81.1 ± 5.3 and while at 48 hours it ranged from 62.8- 92.2 with mean score 83.26 ± 5.3. The t- test for equality of means was applied to assess maternal- infant bonding at both 24 and 48 hours by assuming equal variances. The value of t at 24 hours and at 48 hours was -7.428 and -8.894, respectively p = 0.000 at both 24 hours and 48 hours. This shows that there was significant difference in bonding score in the control and experimental group both at 24 hours and 48 hours of the delivery (Table 3)
Table 1- Socio- demographic profile of the subjects.
| SOCIO- DEMOGRAPHIC PROFILE | Control Group f (%) | Experimental Group f (%) |
| N=109 | N=109 | |
| Age Group
– £ 20 years |
05 (04.6) |
03 (02.8) |
| – 21- 25 years | 57 (52.3) | 49 (45.0) |
| – 2f (%)6- 30 years | 34 (31.2) | 43 (39.4) |
| – ³ 31 years | 13 (11.9) | 14 (12.8) |
| Education (self) | ||
| – Till 10th | 60 (55.1) | 40 (36.7) |
| – 10th to 10+2 and diploma | 20 (18.3) | 25 (22.9) |
| – Graduation and above | 29 (26.6) | 44 (40.4) |
| Occupation (self) | ||
| – House-wife | 97 (89.0) | 24 (22.1) |
| – Employed | 12 (11.0) | 76 (77.9) |
| Place (Habitat) | ||
| – Rural | 73 (66.9) | 57 (52.3) |
| – Urban | 36 (33.1) | 52 (47.7) |
| Per Capita Income | ||
| – £Rs 500 | 19 (17.4) | 16 (14.7) |
| – Rs 501 – Rs 1000 | 63 (57.8) | 51 (46.8) |
| – Rs 1001- Rs 2000 | 12 (11.0) | 20 (18.3) |
| – = Rs 2001 | 15 (13.8) | 22 (20.2) |
| Type of Family | ||
| – Joint | 79 (72.5) | 75 (68.8) |
| – Nuclear | 30 (27.5) | 34 (31.2) |
Table 2 : Gravida status, gestation period and sex of baby of the subjects
VARIALES Control Group Experimental Group f (%) f (%)
N=109 N=109
Gravida
– Primi Gravida 38 (34.9) 47 (43.1)
– Multi Gravida 71 (65.1) 62 (56.9)
Period of Gestation (in weeks)
| – | 36- 37 | 14(12.8) | 17 (15.6) |
| – | 37+1- 40 | 83(76.1) | 82 (75.2) |
| – | 40+1 and above | 12 (11.1) | 10 (09.2) |
| Sex of baby
– |
Boy |
48 (44.1) |
57 (52.3) |
| – | Girl | 61 (55.9) | 52 (47.7) |
Table 3 : Maternal- infant bonding score at 24 and 48 hours
| TIME | Maternal- Infant bonding Score | Value of t | |||
| Control Group (N=109) | Experimental Group
(N=109) |
||||
| Mean ± S.D | Range | Mean ± S.D | Range | ||
|
After 24 |
73.6 ± 9.0 |
44.5- 89.2 |
81.1 ± 5.3 |
62.4-91.0 |
-7.42 |
| Hours of | (p=0.000) | ||||
| delivery | |||||
| After 48 | 74.5 ±8.9 | 44.5-92.2 | 83.3 ± 5.3 | 62.8-92.2 | -8.894 |
| hours of | (p=0.000) | ||||
| delivery | |||||
The significant higher level of maternal infant bonding score was observed in experimental group as compared to control group in relation to gravida status and gestation period of subjects. It was further observed that in control group, 8 (7.3%) multigravida subjects had poor bonding as they scored less than 60.2 while no primigravida subjects scored less than 60.2. while on the other hand neither primigravida subjects nor multigravida mothers in the experimental group had poor bonding. As per period of gestation it was bserved that only eight subjects from control group had poor bonding The perid of gestation of 5(4.6%) subjects was 37+1 to 40 weeks of period of gestation while one subject (0.9%) had 36 -37 weeks gestation and another two (1.8%) subjects had 40+1 and more gestation and non of the subjects in experiment group had poor bonding.
The variables like maternal education, occupation, habitat, per capita income presence of medical disorders during pregnancy, sex of baby, pre lacteal feeds and bir th weight of baby had on impact on maternal infant bonding in both the groups.
Table 4 depicts the maternal- infant bonding score of the subjects according to reasons for not initiating breast feeding within an hour of the delivery in the control group. The reasons were lack of rooming in and non willingness on mothers par t. There was significant difference in the scores.
Table 4 : Maternal- infant bonding score as per reason for not initiating breast feeding within an hour of delivery
| GROUP | Reasons | Poor bonding | Good bonding |
| f (%) | f (%) | ||
| Control | Lack of rooming-in | 4 (5.1) | 75 (94.9) |
| Mother not willing | 4 (13.3) | 26 (86.7) |
p =0.007 <0.05 at df=1 (X2 test)
Discussion
In spite of an increased focus on the early initiation of breast feeding, the practice of initiation of breastfeeding varies from institution to institution. Studies have been done to assess the effect of early initiation of breastfeeding. But very few studies have been done so far, to assess the effect of initiation of breastfeeding within one hour of the delivery on maternal- infant bonding. Though W.H.O prescribes that breastfeeding should be initiated within half hour of delivery, but the practice varies within different institutions. PGIMER, Chandigarh is a referral hospital and most of the complicated and high risk cases come for the delivery, so in most of the cases condition of mother is not stable within half an hour after the delivery. But it is possible to initiate breastfeeding within one hour of the delivery. So this study was taken up with the objective, to assess the effect of initiation of breastfeeding within one hour of delivery on maternal- infant bonding.
In the present study, mother- infant dyads after normal vaginal delivery were taken as the study subjects, as most of the mothers deliver baby normally. For this reason a number of other researchers have also preferred to take subjects after normal vaginal delivery. The study subjects (mothers) in the present study were both primigravida and multigravida.
Assessing maternal- infant bonding has been a tremendous challenge among researchers because it involves the study of psychology of the mother about her attachment to the new born baby. Researchers have studied other benefits of early initiation of breastfeeding. In present study, Maternal Postnatal Attachment Scale (MPAS) was used to objectively assess maternal- infant bonding on the basis of feelings and behavioral responses of mother towards her new born baby. The tool was standardized but modified as per the need of the study and after modification it was checked for its reliability by Cronbach’s alpha. It was found reliable.
Studies depict that mother- baby bonding is enhanced by breast feeding.18 Sucking enhances the closeness and new bond between mother and baby.19 The findings of the present study revealed that with the initiation of breastfeeding within one hour of delivery, bonding increases between the mother and her new born baby. It is likely to be caused by early skin-to-skin contact when the mother breast feeds. The remarkable change in the maternal behavior with just the touch of the infant’s lip on the mother’s nipple, the reduction in the abandonment with early contact, suckling and rooming- in and the raised maternal oxytocin levels shortly after bir th in conjunction with known sensory physiologic, immunologic and behavioral mechanisms all contribute to maternal- infant bonding.4
A study was conducted to find out the pattern and influence of socio- cultural factors on breast feeding practices in the rural mothers of Darjeeling district. Result showed that, 85.5% of the mothers initiated breast feeding within 7-18 hours after delivery, 55% of mothers got the information from their family members. Education and socio-economic status had a significant association with duration of breast feeding.20 Whereas in the present study, house-wife mothers predominated in both the groups. The findings of the study revealed that there is no significant difference in bonding scores of house-wife and employed mothers as the number of employed mothers was less.
In an another study conducted by Anteo Di Napoli et al, to evaluate the effects of level of education on the initiation and duration of breast feeding. Results showed that a low level of education, determines a negative effect on the initiation and duration of breast feeding.21 As researchers repor t that there is a significant effect of education and socio- economic status of the mother on initiation of breastfeeding and thus bonding, so in the present study, bonding scores within mothers of different educational status and socio-economic status were compared. The findings of present study revealed no significant difference in the bonding among mothers of different groups. Findings also indicate that gender of the baby does not influence the bonding among mothers. The results depict that giving pre-lacteal feed to the baby also has no effect on the maternal- infant bonding scores.
The results of the present study signifies that with the initiation of breastfeeding within one hour of delivery, maternal- infant bonding is improved as compared to initiation of breastfeeding after one hour of delivery.
The present study depicts that the age of the subjects ranged from 19 years to 41 years in both the groups. Majority of the subjects i.e. 52.3% mothers in the control group and 45% mothers in the experimental group aged between 21- 25 years. Any disease during pregnancy was present in very few mothers during pregnancy i.e. 16.15% in the control group while 20.18% in the experimental group. The most common disease which the subjects were having was hypothyroidism in both the groups. In control group, 76.15% mothers had period of gestation between 37+1 – 40 weeks while in the experimental group 75.23% mothers had period of gestation between 37+1 – 40 weeks. Study subjects were comparable as per the birth weight of the baby in both the groups. On maternal infant attachment scale, the mean net bonding scores of mothers in control group was 73.6 at 24 hours and 74.5 at 48 hours whereas for experimental group, it was 81.1 at 24 hours and 83.2 at 48 hours of the delivery. The value of t at 24 hours and 48 hours was -7.428 and -8.894, respectively. Null hypothesis was rejected (p= 0.000 < 0.05). Statistical significant differences were seen between the bonding scores of mothers who initiated breast feeding within hour of the delivery and the mothers who initiated breast feeding after one hour of the delivery. Based on the findings, the study recommends that breast feeding should be initiated within one hour of the delivery. A similar study using the same tool after 6 weeks and one year of the delivery can be taken up to provide further impetus to the findings. A similar study using interview technique along with the “maternal-infant bonding tool” can be done to further refine the findings. The findings of the study provides An evidence-based data for the improvement of “maternal- infant bonding.” Hence feeding in the first hour of delivery is recommended to improve maternal – infant bonding.
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