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Special Communication


Habib, Fawzia Ahmed MD

Author Information
Journal of Family and Community Medicine: Sep–Dec 2003 - Volume 10 - Issue 3 - p 41-46
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Breast milk is considered a uniquely superior infant feed, providing various medical and psychological advantages over formula feeding. It is not only important for health, nutrition and the development of a baby's trust and sense of security, but also enhances brain development and learning readiness.1 Breastfed babies have fewer attacks of ear infections, which have been associated with hearing loss and learning delays.2


Healthy newborn infants are often separated from their mothers after delivery and may not be put to the breast for hours, or sometimes for days while waiting for the milk to come in. This can happen with both hospital and home deliveries, in traditional and modern settings. The practice is potentially detrimental to both breastfeeding and the development of mother/infant relationship often referred to as “bonding”. The American Academy of Pediatrics recommends that breast-feeding should begin within the first hour of life, rather than hours after birth.3 Early skin to skin contact and the opportunity to suckle within the first hour or so after birth are both important. Some contact is inevitable when attempting to breastfeed but contact itself does not necessarily result in immediate suckling. However, contact and suckling are so closely interrelated that most studies reviewed have used the terms interchangeably, and few researchers distinguish clearly between them.45 Several randomized studies have examined the influence of early postnatal contact on the initiation and continuation of breastfeeding. Widstrom et al,5 suggested that early touch of the nipple and areola (within 30 minutes) might positively influence maternal/infant relationship during the first days after birth. Early suckling can increase postpartum uterine activity and may reduce the risk of postpartum hemorrhage. Chua et al,6 in Singapore, recorded uterine activity in 11 women immediately after delivery of the placenta before, during and after breastfeeding or manual nipple stimulation. The median increase with manual stimulation was 66%, and with breast-feeding was 93%. A meta-analysis of these seven studies by perez-Escamilla et al,7 concluded that early contact had a positive effect on the duration of breast-feeding at 2 or 3 months (P<0.05). A cross-sectional study conducted on 726 Primi para women and their babies in the USA revealed that mothers were less likely to breastfeed exclusively in hospitals if the first feed occurred 7 to 12 hours postpartum or more than 12 hours postpartum.8

The objective of this study is to encourage the Obstetrics & Gynecology Unit of King Khaled University Hospital (KKUH) in its endeavor to follow the ten policies of Baby Friendly Hospital Initiative. Accordingly, the nurses were taught about breastfeeding in detail and the mothers were given assistance to breastfeed their babies within one hour of life. The reaction of the nurses and others involved during the initial stage of implementing this new practice was that, (1) it was not possible, (2) the women would not agree, (3) the babies would not suck etc. Gradually the nurses came to understand that it was possible to help women breastfeed their newborns within half an hour of birth. The nurses now assist women to breastfeed their babies; a practice which started few months ago. This descriptive study was undertaken to find out the extent to which women breastfed their babies in the labor room and what the reasons were for not breastfeeding. This survey is to be repeated every six months to monitor progress and based on the findings of the study to plan strategies to improve the practice of breastfeeding.


A descriptive study design was used. Early breastfeeding was instituted by assisting the mother to breastfeed her baby within ½ an hour to 1 hour of birth. The setting was the labor and delivery room of KKUH which had 17 beds. The delivery rooms of 8 beds have an annex of 5 beds and a 1st stage room with four beds. There is an operating theatre and two rooms for the resuscitation of babies. The majority of the patients were delivered normally, (85%) by forceps, ventouse and the remaining (15%) were delivered by lower segment cesarean section. More than 70% of our patients were high-risk patients. The majority of the nurses working in delivery room were midwives. All the women who delivered in the labor and delivery unit of KKUH during the months (5) of Jumada I and (11) Dhulqada formed the target population. The sample size was 287 in the month (5) of Jumada I 1422H and 315 in the month of (11) Dhulqada 1422H. All the available samples for both months were included in this study. A concurrent audit was done to collect the data for the study. A structured form was used to assess the extent of feeding and the reasons for not breast-feeding. Data will be collected the same way every six months till 100% of the women delivering in the hospital breastfeed their babies in the Labor room. The frequency and the percentage were used to compare the data. The statistical tests of significance will be used after 2 years of data collection.


The majority of the women who were included in the study, 42.5% of 287 in Jumada I (J1) and 45.6 % of 318 in Dhulqda (Dq), were multigravidae. The primigravidae (26.7%) were fewer in Dq than those (37.6%) in J1, whereas the percentage of grand multigravidae (above gravida six) were more (27.7%) in Dq than in J1(19.9%) as shown in Figure I. The percentage of those women who were delivered by caesarean section was more in Dhulqada than in Jumada I. However, the number of women who had spontaneous vaginal delivery, ventouse and assisted breech deliveries were fewer in Dhulqada than in Jumada I, as shown in Figure 2. It is very encouraging to see that there is a definite improvement in the initiation of breastfeeding in the labor room. In Dhulqada, 60% of women initiated breastfeeding in the labor room as compared to 54% Jumada I, as shown in Figure 3. Though the percentage of women who initiated breastfeeding seems low (6%), it was not easy to encourage them to breastfeed, considering the shortage of staff, the language barrier, between new nurses with very little knowledge of Arabic and the refusal of the majority of patients to breastfeed their babies. Despite these problems, nurses still made the effort and to some extent the patients were cooperative.

Figure 1:
Demographic Data – Gravida
Figure 2:
Demographic data – Mode of delivery
Figure 3:
Comparison on initiation of breast-feeding within half-an-hour of delivery in Jumad-I & Dhulqada

Figure 4 explains that in Jumada I, there was no difference between the primi, multi, or grand multigravidae but in Dhulqada the multigravidae showed an improvement (11.9%) in initiating breastfeeding as compared to primigravidae (1.9%) and the grand multigravidae (3.1%).

Figure 4:
Comparison on initiation of breastfeeding on gravida

This shows that primigravidae and the grand multigravidae need more encouragement and education during the antenatal period. Much effort should be focused on the primigravidae, since women tend to repeat whatever they do in the first pregnancy in the subsequent ones. There are many factors related to the noncompliance of the initiation of breastfeeding within ½ an hour of birth. Some of these are the lack of knowledge, coming to labor room without enough nourishment as a result of which they are tired, lack of motivation and the lack of family support. Figure 5 shows that in both months a majority (almost all) of women who had caesarean section did not breastfeed their babies though most of them underwent caesarean section under spinal anesthesia, and were fully conscious post delivery. There was not much difference in the initiation of breastfeeding in the other two groups, i.e., spontaneous vaginal delivery (70.2%) and ventouse (66.6%) in the month (11) of Dhulqada. Whereas there was a vast difference in terms of noncompliance in the mothers who were delivered by ventouse (33.3%) as compared to those who delivered spontaneously (60.7%) in the month (5) of Jumada I, it is interesting and encouraging to note that the women who delivered by ventouse in Dhulqada (66.6%) were more compliant as compared to those who delivered by the same means in Jumada I. Whether this increase is accidental or the result of increased awareness in this group remains to be seen since there is little difference between spontaneous vaginal delivery and ventouse, for both groups are able to perform the same functions post delivery. However, the nurses should continue to educate and encourage all new mothers to breastfeed their babies irrespective of the mode of delivery. The variety of reasons given for not initiating breast-feeding within ½ an hour to 1 hour after birth are shown in Figure 6. It was obvious from the study that none of the patients who underwent cesarean section breastfed their babies though cesarean birth is not a contraindication for breastfeeding. Breastfeeding provides some advantages to the mother who has had cesarean section. For instance, suckling stimulates the mother's uterus to contract more quickly and speed her healing. Breastfeeding brings mother and baby emotionally closer, which may be especially important if they are in separate rooms or the birth was traumatic.

Figure 5:
Comparison on initiation of breastfeeding on mode of delivery
Figure 6:
Comparison of reasons for not initiating breastfeeding in labor room

The establishment of the practice of initiating breastfeeding within ½ an hour to 1 hour for women in the recovery room requires a lot of education for the health team members, as well as the patients. It is gratifying that the number of women who refused to breastfeed their babies fell from 13.2% in Jumada I 1422H and by an additional (4.1%) in Dhulqada. This may be the result of the education they had in the antenatal clinic and the wards. The percentage of women who said they were tired and therefore could not feed their babies in Jumada I was 10.8 % as compared to 8.5% in Dhulqadqa. Though there was some reduction after 6 months, the educators should persist in teaching the patients how to prepare themselves for delivery. Some women take only fluids from the time contractions start and some neither eat nor drink anything from the start of contractions. Some women waste their energy by bearing down unnecessarily and so feel very tired after delivery. There is a great need therefore, for formal parenthood classes in the antenatal clinics. The majority of women who were given pethidine during labor did not initiate breast-feeding in labor room. The medication given during labor may have interfered with the early development of breastfeeding and delayed the first breastfeed. In addition, these women also felt dizzy and so refused to feed their babies in the labor room.


It is encouraging to note there has been a 60% improvement in the half a year. In the year 2001, no babies were breastfed by their mothers within one hour of birth. Now, however, there is a steady improvement in the number of women who breastfeed their babies in the labor room. It is gratifying that the number of women refusing to breastfeed has fallen considerably.

Our recommendations are: (1) Prepared parenthood classes must be conducted in the antenatal clinics regularly, so that every expectant mother can be taught and prepared to breastfeed her baby early. (2) All patients on admission to the labor room must be informed that they should expect to breastfeed their babies within ½ an hour to 1 hour after birth. (3) The Obstetrics Departments must have health educators and lactation nurses to promote and achieve the baby friendly hospital policies. (4) All the health team members must encourage women to breastfeed their babies.


The author is grateful to Sister Rajakumari Ravi, Associate Director of Nursing in the Obstetrics and Gynecology Department, King Khalid University Hospital, for her help in making King Khalid University Hospital a Baby Friendly Hospital.


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3. American Academy of Pediatrics. . Policy statement: Breastfeeding and the use of human milk Pediatrics. 1997;100(6):1035–9
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8. Kurini JN, Shiono PH. Early formula supplementation of breastfeeding Pediatrics. 1991;88(4):745–50

Breastfeeding; newborn; King Khalid University Hospital; labor room

© 2003 Journal of Family and Community Medicine | Published by Wolters Kluwer – Medknow