Implementation of the first breastfeeding in warsaw's maternity hospitals

The first hours after birth are considered to be the most important stages in human development. They are defined as a decisive time in life. The newborns nervous system is particularly sensitive to negative stimuli. The recommended method of facilitating adaptation to extrauterine life is skin-to-skin contact and the first breastfeeding [1].

In the 1980s, the World Health Organization (WHO) issued recommendations highlighting the need for skin-to-skin contact. The “Child Friendly Hospital” program was created, whose overall goal is to promote activities supporting and promoting breastfeeding in healthcare facilities in the form of “10 steps to successful breastfeeding.” In Poland, the recommendations in the Regulation of the Minister of Health on the organizational standard of perinatal care are currently in force, regulating postpartum care procedures including 8 out of the 10 steps. They include mother-child contact, which consists of placing a naked child on the mothers chest/stomach before cutting the umbilical cord and the first breastfeeding of the newborn baby after birth. The mother’s contact with the child may be interrupted only for medical reasons in the event of a threat to the life or health of the mother and/or child [2, 3, 4].

Attaching the baby to the breast has an impact on the course of lactation and its duration. Early breast sucking begins the production of food and promotes lactogenesis by secretion of prolactin (which is released from the anterior pituitary as a result of the stimulus of sucking) and oxytocin (from the posterior pituitary). Many studies have shown a relationship between skin-to-skin contact with the mother together with early initiation of the first feeding and exclusive breastfeeding at discharge from the hospital and up to three or even six months after birth [5, 6, 7, 8]. The test results also apply to cesarean sections. In the group where the first breastfeeding began early, newborns were exclusively fed with mother’s milk up to the age of three months [9].

The first feeding during contact with the mother is of particular importance at many levels, both for mother and baby. The advantages resulting from early breastfeeding are:

A significant benefit resulting from early breastfeeding is the colonization of the digestive tract of the newborn by the mother’s commensal microbiota. An important role is played by colostrum - the first food. Compared to mature foods, it contains less fat and lactose, more vitamin A and protein, which prevents severe neonatal jaundice by speeding up meconium excretion. It also contains bacteria of the genera Lactobacillus and Bifidobacterium and olisaccharides that affect their development. Colostrum contains high levels of antiinflammatory factors and cytokines and antibodies (Class A secretory immunoglobulin) [18, 19].

The aim of the study was to assess the provision of the first breastfeeding after natural delivery in Warsaw’s medical facilities in the light of the current Perinatal Care Organization Standard and WHO guidelines regarding the mother’s first contact with the child.

The method of direct observation was used in the study. The research material was collected using the authors’ observation sheet designed for the purposes of the study.

The sheet contained:

Criteria for inclusion in the study:

The tests were carried out in 11 Warsaw obstetric facilities with varying degrees of referentiality, in which the management agreed to conduct the study. It was ensured that the data collected would be presented anonymously. The research began in January 2016 and was completed in December 2017.

The analysis included 304 observations. The number of observations in a given hospital was determined proportionally on the basis of the annual summary of the number of deliveries in Warsaw in 2015. The persons conducting the study were trained how to run the observations before the start of the study and were not employed in the facilities where the study was conducted. The observations were carried out from the moment the child was born until the end of the fourth delivery period. The observers recorded the results obtained on an observation sheet.

The studies were carried out in hospitals with varying degrees of reference. There were 6 hospitals with the 3rd reference level - 176 observations (57.89%), 4 hospitals had the 2nd reference level -117 observations (38.49%), 1 hospital had the 1st reference level, and 11 observations were made there (3.62%) (Table I).

Analysis was conducted of 304 observations of deliveries completed by natural labor. The shortest gestation was 35 weeks and the longest 41 weeks. The average time of completion of pregnancy in the study group was 39.11 ± 1.12 (Table II).

In the group of newborns that was observed, 97.70% were mature, healthy children, 2.30% were prematurely born in good general condition (Table III).

The analysis of data on the number of points on the Apgar score obtained in the first minute of a child’s life showed that 86.52% of the newborns scored 10 points, 7.89% were rated 9 points, and 5.59% scored 8 (Table IV).

In the 5th minute of life, 99.34% of newborns obtained 10 points on the Apgar score, 0.66% were rated 9 (Table V).

During the direct contact of the mother with the child in 97.37% of the cases the newborn was attached to the mother’s breast. In 2.63% of the cases, the newborn was not attached to the breast (Table VI).

In 44.40% of the cases the newborn was attached to the breast by a midwife, 35.20% a midwife student, and in 10.53% a mother without instruction. In 5.92% of cases, the attachment took place after the midwife’s instruction. Some cases of the newborns independent attachment to the breast were noticed. These accounted for 1.32% of the cases. The “Not applicable” group are cases in which the newborn was not attached to the breast (Table VII).

The duration of the first breastfeeding was analyzed. In 25.01% of the cases it lasted over 30 minutes, in the same number of feedings it ranged from 21-30 minutes. The shortest feeding time from 1-5 minutes was observed in 5.58% of the cases (Table VIII).

Breastfeeding (in exceptional cases a bottle with breast milk) is the proper way to feed newborns and young children. The superiority of breast milk over dairy formula based on cow’s milk was recognized by WHO, UNICEF (United Nations International Childrens Emergency Fund), AAP (American Academy of Pediatrics), ESPGHAN (The European Society for Paediatric Gastroenterology Hepatology and Nutrition) and EFSA (European Food Safety Authority). As early as 1974, WHO announced the value of exclusive breastfeeding in the first months of life. Currently, many institutions and organizations on a global and local scale are undertaking activities to support this diet [18, 20, 21, 22]. In 1990, the initiative “Child Friendly Hospital” was created, whose main task is to disseminate practices that promote and support breastfeeding in healthcare facilities in the form of “10 steps to successful breastfeeding.” Their content (with minor modifications) was unchanged. In 2017, WHO published a new edition of the document ‘Protection, promotion and support of breastfeeding in obstetric and neonatal care facilities’, which contained the updated TO steps to successful breastfeeding’. The current document has been divided into two parts. The first contains management procedures for successful breastfeeding, the second gathers key clinical practices for breastfeeding. The fourth step provides tips to “enable mother and baby to have uninterrupted” skin-to-skin “contact as soon as possible after delivery and help her initiate breastfeeding as soon as possible, help a woman start breastfeeding within half an hour of having a baby” [20].

Immediate skin-to-skin contact and early initiation of breastfeeding are two closely linked aspects that must occur together to achieve optimal benefits [2, 5, 9, 12, 23, 24, 25, 26]. Such contact stimulates the newborn’s search reflex, which helps him find the breast and then suck it, thus initiating food production and supporting lactogenesis [16]. The first feeding should last without interruption until natural completion. If the newborn actively sucked the breast immediately after birth, he or she may not show the desire to suck, nor indicate hunger for the next 12 hours [5, 27].

In our own research, it was noted that during the direct contact of the mother with the child, the newborn was attached to the mother’s breast in most cases (97.37%). In 25.01% of our cases, the first feeding lasted over 30 minutes and the same number of feedings took from 21 to 30 minutes. Only in 5.58% of the cases was it short - from 1 to 5 minutes. Such a well-initiated first feeding indicates that the majority of hospitals implement the fourth step of the “10 steps ...” although according to KUKP

awarding the title, KUKP confirms that a given health care facility carries out all the” 10 Steps ... ,„ is comparable with decorated facilities from around the world, and its course of conduct serves the best interests of the child and mother, enabling breastfeeding. At the same time, the „International Marketing Code for Feminine Milk Replacement Products” is fully respected in such an institution, giving mothers the chance to make a decision to feed their child based on modern medical knowledge, not on advertising. “[28]