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Year : 2017  |  Volume : 10  |  Issue : 6  |  Page : 1756-1762
Impact of skin-to-skin care on satisfaction and experience of cesarean mothers: Arandomized, double-blinded clinical trial

1 Department of Pediatric Nursing and Medical Surgical, School of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
2 Department of Pediatric Nursing, Student Research Committee, School of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
3 Department of Statistics and Epidemiology, Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
4 Department of Pediatrics, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran

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Date of Web Publication11-Jan-2018


Introduction: During the infancy period, it is vital to take a good care of mother and infant to promote their health. Furthermore, mothers' satisfaction is a good indicator to evaluate the quality of services. Objective: The aim is to examine the impact of skin-to-skin contact of infants by mother immediately after caesarean on the satisfaction of the mothers and to study the experience of mothers who received the care. Materials and Methods: This randomized, controlled, double-blinded clinical trial performed on the mothers who had cesarean in 2015 in Miandoab city, West Azerbaijan Province, Iran. One hundred and five participants were randomly divided into the experiment and control groups using randomized blocks method. Experiment group received skin-to-skin contact in the recovery room, and then, for 3days, at 7 am, 1 pm, and 7 pm for 30min. To measure the satisfaction of the mothers, a questionnaire, previously was approved, was applied. Experience of the mothers with the kangaroo mother care method only in the experiment group was measured. Results: Mean satisfaction of mothers in the experiment group was significantly higher than the control group(P<0.001). The experience of mothers for skin-to-skin contact in the intervention group was close to “totally agree=5.” In the multivariate analysis, based on backward method, the age was the only significant variable with an odds ratio of 1.90 and B=0.64 and 95% confidence interval for the B value(1.14, 0.14) which was statistically significant with mothers' satisfaction(P=0.013). Conclusion: Skin-to-skin contact of infants by mothers might be improves mothers' satisfaction and postnatal care.

Keywords: Kangaroo mother care, mother's experience, mother's satisfaction, skin to skin contact

How to cite this article:
Jabraeili M, Seyedrasouli A, Kheiri Z, Sadeghi-Bazrgani H, Jannatdoost A. Impact of skin-to-skin care on satisfaction and experience of cesarean mothers: Arandomized, double-blinded clinical trial. Ann Trop Med Public Health 2017;10:1756-62

How to cite this URL:
Jabraeili M, Seyedrasouli A, Kheiri Z, Sadeghi-Bazrgani H, Jannatdoost A. Impact of skin-to-skin care on satisfaction and experience of cesarean mothers: Arandomized, double-blinded clinical trial. Ann Trop Med Public Health [serial online] 2017 [cited 2020 Oct 25];10:1756-62. Available from:

   Introduction Top

Annually, about 287,000 pregnant women die due to the pregnancy complications, of which 99% occur in low-and middle-income countries.[1] Due to the problems in providing services, there is an emphasis to increase available services and maintain the status quo in the quality of services in developing countries.[2]

The initial phase of transition of the fetus to the postnatal period is a very important, sensitive, and stressful phase. The care practices which provide better integration with the environment can play a key role in adaptation and evolution of the infant.[3]

Kangaroo mother care(KMC) is a standardized method based on mother and infant skin-to-skin contact.[4] Skin contact between mother and baby immediately after birth provides a perfect setting to accommodate the infant with life outside the womb,[5] and it is also an opportunity to begin breastfeeding.[6] The positive impacts of KMC include meeting the baby's needs for warmth, breastfeeding, protection from infection, stimulation, safety,[7] reducing the death, pain, anxiety, length of hospital stay, and also the increased satisfaction of the mother, increased duration of breastfeeding, and it also improvement in the emotional connection between mother and baby.[8],[9],[10] In addition, the KMC increases the ability to care the baby, the self-confidence and a sense of connection in mothers.[11]

Patient satisfaction is an important indicator of the quality of health-care services.[12] Patient satisfaction is a concept that today has special importance in medical care. Patient satisfaction is the assessment of the patient about received health care.[13] Furthermore, it is a basic prerequisite for improving the health services and the budget allocation.[14],[15]

The World Health Organization has recommended paying attention to the mothers' satisfaction to assess the quality and effectiveness of health services.[16]

Studies have shown that mothers' dissatisfaction may lead to noncompliance with service providers and willing to change to another care provider.[17] In addition, mothers' dissatisfaction in neonatal care units may lead to negative psychological effects such as posttraumatic stress disorder, reluctance to get pregnant again, tend to choose caesarean section and abortion, negative interaction between mother and infant, and eventually the inability to establish effective relationship with the husband.[14],[18],[19] Patient satisfaction is an important outcome in health services system,[20] and is increasingly getting attention in low-and middle-income countries.[21],[22] In Indonesia, the most important factors on patient satisfaction are the services provided by nurses and physicians.[23] In Ghana, the mothers' satisfaction during labor is mostly associated with treatment providers.[24] The previous studies have shown that patient satisfaction on the performance of health services ranges from 47.1% to 96.7%.[25],[26] A study in Iran showed that 85.50% of the mothers' satisfaction can be predicted by medical care, nursing care, good and calm environment.[27]


This study aimed to determine the effect of skin-to-skin contact between mother and baby after C-section delivery on mother's satisfaction.

   Materials and Methods Top

Ethical issues

Protocol of the study was reviewed and approved by the Ethics Committee of Tabriz University of Medical Sciences. Informed consent of all participants was obtained, and the data collection was done confidentially. This study was registered in the Iranian national registry of clinical trials under number of IRCT201506064617N12.

Study design

This was a randomized, controlled, double-blinded parallel clinical trial conducted in a single center during August to December 2015. Data were collected by blinded interviewers.

The study design is presented in [Figure1] and it is described according to the CONSORT 2010 statement.
Figure1: Consort 2010 flow diagram

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Study site

This study was performed in Fatemeh Zahra Hospital of Miandoab city, West Azerbaijan province, Iran, which is affiliated to Uremia University of Medical Sciences.

Study population

Inclusion criteria: Mothers who had cesarean section with spinal anesthesia; term infants(fetal age of 37–42weeks), and Apgar score of above 7 at 5min after birth.

Exclusion criteria

Mothers with a history of antidepressive medicines or psychotropic drugs, smoking or addiction, infants with the diagnosis of pathological icterus, or factors that intensify icterus, such as cephalohematoma.

Sample size

Assuming a 5% typeI error(α = 0.05), 10% typeII error (β = 0.10, power=90%), the mothers' satisfaction was considered as the main variable; and assuming a 20% loss during the study, the sample size of 50cases in each group was calculated by SPSS 11 software.[28]

Mothers admitted for cesarean section who had the inclusion criteria were registered in the study. After explaining the objectives of the study to the participants and filling up the written consent form by them, a Ralloc module was created and the participants were divided into the control and experiment groups using random block method in 1:1 allocation. The random sequence was done by statistical software STATA11 (College Station, TX: StataCorp LP). Randomization was performed using the fixed size block randomization method, and the opaque-sealed numbered envelopes were used to cover allocation concealment. Random allocation was done by central call system.


For the mothers in the experiment group, kangaroo care method was trained by the researcher before cesarean, and the mothers in the control group were received routine care. Then, the infants in the experiment group were put nakedly vertically on their mothers' breast and covered with warm and dry blanket and a hat was placed on babies' head to prevent heat loss. The KMC performed with support of the researchers in the recovery room for 30min. The process repeated in the inpatient ward three times a day, each time for 30min on the 7 am, 1 pm, and 7 pm until the day of discharge(3rdday). Privacy was taken into account during the KMC.

The study variables included demographic variables consisting of mother's age, mother's education, gender of the infant; gestational age and history of abortion. To measure the satisfaction of the mothers, a questionnaire was used which was previously used in the study of Nahidi et al. and its reliability and validity were approved using test-retest and concurrent methods.[28]

To assure the inter-rater reliability of the instrument, the questionnaire filled for first 10 participants by two nurses who were unaware of the objectives of the study and the allocation of the samples to the groups. To determine the agreement score between the two nurses, Cohen's Kappa coefficient was used. The agreement was calculated as higher than 0.70, which is considered as good agreement. Experience of the mothers with the KMC only in the experiment group was received a score of “I strongly agree(5),” “I agree(4),” “I have no idea(3),” “I disagree(2),” and “I strongly disagree(1),” with the minimum score of 1 and maximum score of 5.

Statistical analysis

Data were analyzed using statistical software(SPSS Inc., Chicago, IL, USA) Version22 based on the intervention principle of intention to treat. Normality dispersion of variables was assessed by Kolmogorov–Smirnov test. The descriptive specifications of the participants were presented with statistical markers for quantitative variables using central indexes involved mean and median and dispersion indicators of standard deviation and interquartile range. Nominal and ordinal qualitative variables presented by frequency(relative frequency). Chi-square test was used to examine the possible relationship between the qualitative variables. Fisher's exact test was used in case of the limitations in the expected frequency. Independent samples t-test was used to compare the equality of two means between qualitative variables with the assumption of equality of variances, and Mann-Whitney test was used in case of noncompliance of assumptions. Linear regression was used with the assumption of normality of the outcome variable to predict mothers' satisfaction and checking the remaining items such as case-wise diagnostics. Durbin–Watson was also used to assess linearity. P<0.05 considered statistically significant.

   Results Top

In the present study, a total number of 116 mothers who had C-section were participated, 105 of whom completed the study process. Five cases were excluded based on exclusion criteria. 6cases did not complete the satisfaction questionnaire[Figure1]. The mean age of the experiment group was 28.37(±6.21) and of the control group was 29.13(±5.46). No significant difference was found in the mean age of two groups(P=0.509). In the experiment group, 40cases(74.10%) had secondary school education, 10cases(18.50%) with elementary education level; the highest frequency in the control group was 26cases(51.0%) with secondary school education level, and then, 14cases(27.50%) with elementary education level. There was significant difference in the frequency of the education level divided by the experiment group and the control group(P=0.033). The majority of mothers in both groups were homemakers.

[Table1] compares the satisfaction of cesarean mothers divided by experiment and control group. The average satisfaction of mothers under intervention was significantly higher than the control group in all 9 items.
Table 1: Comparison of the mother's satisfaction in the experiment and control groups

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Experience of the mothers with the KMC in the experiment group was received a score of “I strongly agree(5),” “I agree(4),” “I have no idea(3),” “I disagree(2),” and “I strongly disagree(1),” with the minimum score of 1 and maximum score of 5 is presented in [Table2]. Table shows that the mean and median are close to “I strongly agree.”
Table 2: The experience of mothers for kangaroo mother care method only in the experiment group

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According to [Table3], in the univariate analysis, only the age of the mother had a statistically significant association with predicting the overall satisfaction of the mothers. So that, this variable predicted 76% of the overall satisfaction level.
Table 3: Predicting the level of overall satisfaction of mothers in univariate analysis

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In the multivariate analysis, based on backward method, age was the only significant variable in the final model with an odds ratio of 1.90 and B=0.64 and 95% confidence interval for the B value(0.14, 1.14)(P=0.013).

   Discussion Top

Mother and baby skin-to-skin care is an effective solution and reasonable care for all the babies in the Neonatal Intensive Care Units(NICU). KMC enhances the quality of care and health services. This approach is more cost-effective than clinical treatment or therapeutic techniques.[29]

According to the findings of the present study, the mean satisfaction of the mothers under the intervention was significantly higher than the control group in all 9 item of questionnaire. In the study of Nahidi et al., the majority of mothers in the experiment group were very satisfied with skin-to-skin contact and only 5% were dissatisfied with this method due to the pain from perinea episiotomy repair.[28] KMC method has been approved to perform 96% by mothers, 82% by fathers, and 84% by family members. The impact of KMC on infant behavior, confidence of mother, and breast-feeding was reported up to 57%, 94%, and 80%, respectively.[30] In a study in Iran, a statistically significant difference was found between attachment scores in the pretest and posttest of mothers(P=0.001).[29]

In a study, KMC method during of hospitalization length in the NICU ward was not reducing mother's satisfaction level.[31] In the study of Bitew et al., in Ethiopia, the overall satisfaction of postpartum mothers was 81.70%. Another study in Nairobi showed that unwanted pregnancy is associated with lower levels of satisfaction in mothers; the unpleasant mind set about the pregnancy can affect the experience and satisfaction of pregnant women.[32] A study in India showed that suitable physical condition of baby, and care services received in the period after birth and advices given by health-care workers have impact on the mothers' satisfaction.[33]

The experience of KMC in the experiment group was close to the mean and median central indicators of “I totally agree.” Women's experiences as customers who receive health services are an essential component to assess the quality of health services and to improve the services.[34] Separation from parents, especially the mothers, and admitting in the NICU have negative impacts on mothers and babies and would have a negative emotional impact on children in the future. Some studies have shown a correlation between close connection of premature babies and mother and a positive impact on the babies' relationship with the world outside.[3],[28] Although mothers have the key role in the KMC, fathers have shares directly or indirectly as well.[35],[36] In a study in Iran, performing KMC on the term neonates reduced the stress of both mother and baby. The average score at the end of neonatal period in the KMC group and Congenital Mother Care was 28.42±3.32 and 26.07±4.016, respectively, in the study of Karimi(P=0.02), and in the study of Nematbakhsh was−3.07±3.05 and-1.71±2.91(P>0.01).[37],[38]

In the present study, in the experiment group, the most of mothers had secondary education level, furthermore, and the highest frequency in the control group included with secondary education level and 14cases(27.50%) with elementary education level; there was a significant difference in the frequency of the education level divided by the experiment and control groups(P=0.033). In a study in Turkey, the higher level of satisfaction among the mothers with primary education level showed an inverse relation between satisfaction and education.[39]

According to the findings of present study, age of the mother in the final model with 1.90 odds ratio predicted 90% of the mothers' satisfaction. In another study, the highest mothers' satisfaction was observed in the age group21–30years.[39] While some study showed no significant correlation between satisfaction levels and age.[40],[41] it seems that younger women have lower expectations from medical personnel.

   Conclusion Top

This study showed that skin-to-skin care for neonates can improve the mothers' satisfaction and it is also able to help improving the maternal and postpartum care.


Using two interviewers to collect data, which may be different from each other, can potentially affect the results. However, the interviewers were trained on how to question the participants to reduce this limitation. Furthermore, due to small sample size, gender-specific analysis was not applicable in this study.


Hereby, the cooperation of authorities of Tabriz University of Medical Sciences is highly appreciated.

Financial support and sponsorship

This project was supported by Tabriz University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.

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Correspondence Address:
Ziba Kheiri
Department of Pediatric Nursing, Student Research Committee, School of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ATMPH.ATMPH_642_17

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