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Which measurement tools are available for evaluation of your research? and/or How will you compare the before and after intervention?

attached is the research I’m doing. Please answer based on them. 



PICOT Part II: Skin-to-skin Contact Education for Postpartum Mothers

PICOT Part II: Skin-to-skin Contact Education for Postpartum Mothers

The proposed project focuses on establishing skin-to-skin (SSC) contact as a standard best practice guideline within the maternal and newborn care unit. The initiative is motivated by clinical realities where SSC is overlooked, resulting in increased adverse effects on mother-baby bonding, delays in breastfeeding, increased maternal stress, and higher crying frequencies for the baby. Such implications can result in insistent depressive symptoms, resulting in postpartum depression. Therefore, the following literature review examines findings from scholarly works regarding SSC as a feasible best practice for postpartum mothers within the maternal and newborn care unit in the immediate postpartum period, its benefits, and potential barriers.

Literature Review

Vulnerability of Patient Population

Evidence-based information supports the assertion that postpartum mothers face risks of depression and, thus, are a vulnerable patient population. Literature also exposes the significant role of SSC in countering such risks. For example, Bigelow and Power (2020) conduct a report review focusing on longitudinal research of SSC. The study identifies that mothers within the SSC sample population reported lower depressive symptoms coupled with a more significant reduction in salivary cortisol compared to the control group. This proves that postpartum mothers will likely develop depressive symptoms if best practices are ignored. In this case, the researchers identified salivary cortisol as a mental stress indicator, particularly in the infant’s first four weeks. Motivation for breastfeeding within the SSC group was consistent over the next three months, whereas that of the control sample population declined progressively. Additionally, SSC infants exhibited the still-face effect in the first month, while those within the control group did so a month later. Assessment of mother-child dyads also proved that SSC is a critical factor in helping the development of a desirable mother-infant relationships. A primary strength of the study is that the researchers conducted a follow-up study, providing broader information regarding the impact of SSC after birth. However, a limitation of the study is that the review only focuses on a single longitudinal study. A multiple systematic review would have involved a larger study sample, enhancing the findings’ reliability and significance.

Other studies highlight how SSC is ignored in care. For example, Cadwell et al. (2018) assess the impact of SSC within the first hour of birth. This cross-sectional descriptive-based research utilizes iterative-focused reviews and assessment of video ethnographies and patient record data. The study was characterized by a sample population of 84 mothers and full-term infants in a United States healthcare institution. Following algorithm-based process mapping, the study identified that 31 of the 84 infants, 37%, with no medical issue that could warrant excluding SSC, did not receive SSC (Cadwell et al., 2018). The study’s large sample population is commendable and influences the reliability of findings. However, the study is characterized by limitations such as failure to outline the specific barriers to SSC provision, resulting in research or knowledge gaps.

Effectiveness of Intervention

The PICOT proposes an SSC education program to enhance the mother’s knowledge while reducing the likelihood of depression. Different scholarly works examine the significance of SSC in mothers and infants. For instance, Gupta et al. (2021) perform a systematic review to assess the advantages of SSC on infants with different gestation ages. The systematic review involves 30 scholarly studies performed between 1975 and 2020. The sample population comprises 22 normal-term babies and 8 preterm infants. Analytical assessments reviewed that SSC is essential in stabilizing neonatal physiological parameters among preterm infants. Promoting breastfeeding and supporting mother-infant bonding were other identified advantages. Longitudinal assessments in the study are a core strength, facilitating credibility and generalizability of the research. However, the study sampling process involved two researchers independently searching databases. This lack of a systematic sampling process could have resulted in biases when selecting scholarly papers. Additionally, the sample population of preterm babies is considerably small, negatively affecting the statistical significance of the findings.

Likewise, Jones and Santamaria (2018) explore the physiological advantages of SSC integration in the neonatal intensive special care unit. Specifically, the study relies on an observational cohort research design at a hospital in Melbourne, Australia. The researchers’ objective is to assess SSC’s impact on mothers’ heart rate (HR) and blood pressure (BP). After analyzing variance, the study identifies considerable variations between the SSC mother’s systolic and diastolic blood pressure and that of the control group. The study proves that SSC influences a significant reduction in maternal depressive symptoms and anxieties while also enhancing emotions of bonding with their neonate. Consequently, the study recommends SSC as a critical family-centric care intervention, lowering mothers’ heart rates and blood pressure after birth. A core strength of the research is that it explores a unique physiological effect of SSC, thereby filling past knowledge gaps. However, the study’s limitation is that it involves a small sample size, limiting the amount of parental data for analysis, which can hinder the reliability of findings.

Another study by Casper et al. (2018) provides similar findings by exploring the short-term effects of periodic and prolonged SSC for preterm babies within the neonatal intensive care unit. A retrospective study design characterizes the research. It also involves a sample population of 26 preterm infants with gestation ages ranging between 24 and 28 weeks. The study showed that immediate and periodic SSC was related to a lower prevalence of secondary infections, bronchopulmonary dysplasia, and cholestasis. Longer durations of SSC were subject to a positive correlation with better breastfeeding experiences. The retrospective study design is a considerable strength because it resulted in an in-depth analysis of SSC effects. However, the study could have benefited from a large sample population. Another limitation is that the study ignores the reality that different etiologies, apart from the absence of SSC, can contribute to developing secondary infections.

Apart from the studies highlighting benefits relating to breastfeeding and bonding, Ionio et al. (2021) outline the importance of SSC in regulating stress. Ionio et al.’s (2021) study constitute a systematic review where different studies were assessed to evaluate the impact of contact and touch experienced in SSC on stress regulation. Twenty-two articles published between 2015 and 2020 were selected from an initial target sample of 1141 articles. The researchers assessed biological stress indicators such as the ANS, heart rates, cortisol levels, and oxytocin and identified that SSC significantly reduced stress. The study involves recently published articles, which is a commendable strength. However, the study does not outline the specific patient sample population from the reviewed articles.

Implementation Barriers

Other studies investigate barriers to SSC implementation. Balatero et al. (2019) conducted semi-structured open-ended interviewing with obstetric nurses to identify factors hindering SSC, particularly after cesarean births. Videoconferencing was used in conducting the interviews, and a conventional content analytical method was utilized to assess thematic findings in the data. The sample population involves 10 nursing practitioners. While the nursing practitioners outlined their cognition of the benefits of SSC, they also highlighted the existence of a procedural culture where nurses do not consider SSC a priority after cesarean operations. Other reported barriers included the lack of formal policies and standard procedures and nurse shortages. The use of open-ended interviews was a strength because the researcher encouraged deeper contextualization of the barriers of SSC. However, focusing on just one unit and incorporating a small sample of only 10 medical practitioners is a limitation in the study, which might hinder the generalizability of the findings.

Alenchery et al. (2018) also outline additional barriers, such as staffing shortages, time constraints, and safety concerns. These findings are secondary to qualitative research involving a sample population of 19 obstetrics, 14 pediatrics, and 8 nursing practitioners. Interviews and audio recordings, which were consequently transcribed and analyzed, were the primary data collection methodologies. Interestingly, the study also found various enablers of SSC, such as staff training, interprofessional collaboration, and having designated medical practitioners for SSC. The findings align with Ebrahimi et al. (2022) qualitative research that involved 27 medical practitioners and involved thematic analysis. The study finds that lack of staff training, absence of support from leaders, and lack of supervision are core barriers to SSC implementation. The strength of the two studies is that they incorporate qualitative methods that result in in-depth contextualization of barriers. However, Ebrahimi et al.’s (2022) deal with a small sample size that can impact generalization.


The explored studies by Bigelow and Power (2020) and Cadwell et al. (2018) support the initial supposition regarding the vulnerability of postpartum mothers, especially regarding depressive symptoms and the absence of SSC as a standard best practice in most clinical settings. The studies are reliable, and their findings influence the need to address the identified clinical problem. Consequently, other studies highlight SSC as a feasible best practice for improving mother-baby bonding, reducing mother and baby stress, and enhancing better breastfeeding experiences (Gupta et al., 2021; Jones & Santamaria, 2018; Casper et al., 2018; & Ionio et al., 2021). The findings align with the initial claims that SSC would reduce depression by reducing birth-related stress, enhancing desirable thermoregulation, and reducing cry frequency (Widstrom et al., 2019). However, when implementing the intervention, one will need to focus on barriers identified by Balatero et al. (2019), Alenchery et al. (2018), and Ebrahimi et al. (2022), which entail staff shortages, lack of leadership support, absence of an internal culture where medical practitioners prioritize SSC, lack of standard procedural policies, absence of SSC-based staff training, and inadequate supervision.

Therefore, the objectives of the proposed practice change will involve educating postpartum mothers on the identified SSC benefits and integrating SSC as a standard clinical procedure. The underlying hypothesis is that education will encourage significant rates of SSC adoption even in the postpartum period. The anticipated benefits include improved mother-baby bonding, better thermoregulation, reduced crying frequency, and improved breastfeeding. These benefits will play an important role in countering postpartum depressive symptoms.


The fundamental objective of the project is to introduce SSC education to postpartum mothers within the maternal and newborn care units, resulting in improved self-reported SSC knowledge. The project hypothesizes that the acquired knowledge concerning the benefits of SSC will play an integral role in reducing postpartum depression. The intervention will likely result in reduced birth stress, improved breastfeeding experiences, reduced crying for the baby, ideal thermoregulation, and enhanced mother-baby bonding. These effects will likely act as suitable depression buffers.


Alenchery, A. J., Thoppil, J., Britto, C. D., de Onis, J. V., Fernandez, L., & Suman Rao, P. N. (2018). Barriers and enablers to skin-to-skin contact at birth in healthy neonates- A qualitative study. 
BMC Pediatrics
18, 1–10.

Balatero, J. S., Spilker, A. F., & McNiesh, S. G. (2019). Barriers to skin-to-skin contact after cesarean birth. 
MCN: The American Journal of Maternal/Child Nursing
44(3), 137–143.

Bigelow, A. E., & Power, M. (2020). Mother–infant skin-to-skin contact: Short‐and long-term effects for mothers and their children born full-term.
Frontiers in Psychology,
11, 1–9.

Cadwell, K., Brimdyr, K., & Phillips, R. (2018). Mapping, measuring, and analyzing the process of skin-to-skin contact and early breastfeeding in the first hour after birth. 
Breastfeeding Medicine
13(7), 485–492.

Casper, C., Sarapuk, I., & Pavlyshyn, H. (2018). Regular and prolonged skin-to-skin contact improves short-term outcomes for very preterm infants: A dose-dependent intervention. 
Archives de Pédiatrie
25(8), 469–475.

Ebrahimi, M., Jahanfar, S., Takian, A., Khakbazan, Z., Vazifekhah, S., & Geranmayeh, M. (2022). Barriers of skin-to-skin contact in the first hour of life in healthy term infants: A qualitative study. 
Nursing and Midwifery Journal
20(3), 178–200.

Gupta, N., Deierl, A., Hills, E., & Banerjee, J. (2021). Systematic review confirmed the benefits of early skin‐to‐skin contact but highlighted lack of studies on very and extremely preterm infants. 
Acta Paediatrica
110(8), 2310–2315.

Ionio, C., Ciuffo, G., & Landoni, M. (2021). Parent–infant skin-to-skin contact and stress regulation: A systematic review of the literature. 
International Journal of Environmental Research and Public Health
18(9), 1–14.

Jones, H., & Santamaria, N. (2018). Physiological benefits to parents from undertaking skin‐to‐skin contact with their neonate, in a neonatal intensive special care unit. 
Scandinavian Journal of Caring Sciences
32(3), 1012–1017.

Widstrom, A. M., Brimdyr, K., Svensson, K., Cadwell, K., & Nissen, E. (2019). Skin‐to‐skin contact the first hour after birth, underlying implications and clinical practice. 
Acta Paediatrica
108(7), 1192–1204.



PICOT: Skin-to-skin Contact Education for Postpartum Mothers

PICOT: Skin-to-skin Contact Education for Postpartum Mothers

The immediate care provided to a mother and a newborn immediately after delivery plays a critical role in their short-term acclimatization. However, the absence of standard best practices results in worrying practices such as the separation of mothers and their newborns in the first minutes of life to conduct non-urgent care. Medical practitioners remove the baby from the mother’s chest to provide care that can either be delayed or conducted while the newborn is still subject to skin-to-skin contact with the mother. The unjustified non-urgent care processes often entail injecting vitamin K, applying ophthalmic ointments, and assessing vital signs. Turenne et al. (2016) also finds that the separation of mothers and newborns is prevalent and aligns with considerable postnatal care protocols in various healthcare institutions. Such clinical practices result in increased birth-related stress for newborns and maternal stress that delays breastfeeding and placenta expulsion. Accordingly, limited skin-to-skin contact (SSC) results in higher risks of using formula supplementation because of delayed breastfeeding, higher crying frequencies and intensity, and overall mother and baby stress. Despite the growing body of research supporting the relevance of SSC, Brimdyr et al. (2020) report on a UNICEF finding that only 45% of newborn babies are exposed to immediate SSC and breastfeeding. Moreover, 83% of United States reported SSC, implying that SSC is not practiced in 17% of United States’ hospitals. Accordingly, the PICOT project proposes the integration of an SSC education program for postpartum mothers to improve their SSC knowledge while probabilities of postpartum depressive symptoms.

The quality improvement initiative leverages the following PICOT question: Among postpartum mothers from the maternal and newborn care unit (P), does the integration of a skin to skin contact (SSC) education program (I), compared to control group without this intervention (C), improve knowledge on SSC and reduce the incidence of postpartum depressive symptoms (O), over a period of six weeks (T)? Postpartum mothers are focused population because of their susceptibility to emotional distress and depressive symptoms following after birth, especially when an immediate maternal-and-newborn bond is not attained. An SSC education program will foster requisite self-care skills, facilitating a desirable bond with newborn babies and the related maternal physiobiological benefits. Effectiveness of the intervention will be assessed after comparing results from self-reported surveys that will target SSC knowledge and self-reported depressive symptoms. These outcomes will be assessed after six weeks.

Vulnerable Population

Postpartum mothers are an ideal vulnerable population for this project because of the potential risk factors that can result in postpartum stressors and depressive symptoms. Social determinants of health can influence the depressive symptoms. For example, the lack of financial resources can result in stress and anxiety for women as they worry regarding baby care after discharge. The absence of social support can also exacerbate the probability of maternal stress and postpartum depression (Ghaedrahmati et al., 2017). Lack of social and family support in decision-making can also limit advocacy, which would otherwise influence shared decision-making, resulting in the incorporation of immediate SSC. Education level can also enhance vulnerability of postpartum mothers. A low education level can imply limited literacy, which would act as a barrier to SSC education.


Skin to skin contact (SSC) is a critical best practice because of its considerable advantages to the mother and child. On one end, it enables a newborn to quickly progress through the nine instinctive stages of crying, relaxing, awakening, activity, resting, crawling, familiarizing, suckling, and sleeping. Other benefits entail a significant reduction in the adverse effects of birth-related stress, improved ideal thermoregulation that progresses to the subsequent days, and reduction in cry frequency (Widstrom et al., 2019). SSC also has considerable benefits to the mother. For example, research by Bigelow and Power (2020) find that SSC plays an important role in placenta expulsion, reducing bleeding, and enhancing breastfeeding self-effectiveness. In addition, SSC triggers the considerable increase in mothers’ oxytocin, which plays a critical role in lowering maternal stress level and fostering enhanced mother-infant bonding.

Nursing Theory

The Health Belief Model will be instrumental to the project. This theory helps to elucidate the rationale behind the acceptance or rejection of healthy behaviors by patients. The Health Belief Model will help outline the motivation for mother’s and medical practitioners’ adoption of the SSC practice. The theory argues that health-related behaviors are influenced by factors such perceived susceptibility to a health condition, perceived severity of the condition based on consequences, the assumed benefits of health-promoting actions, perceived hindrances to the ideal action, presence of action enablers, and perception or confidence in one’s ability to engage in the ideal action. In line with the PICOT project, perceived susceptibility to the ignorance of SSC should be highlighted when educating the mothers, considering that Brimdyr et al.’s (2020) study finds that only 45% of newborns are exposed to immediate SSC. Perceived severity of the negative repercussions should also be highlighted to influence a belief of consequences such as the adverse impact on mother-newborn bonding, placenta exclusion, breast feeding, and the newborn’s cry (Turenne et al., 2016). Reducing maternal and newborn’s distress and countering the risks of postpartum depressive symptoms. Perceived hindrances can include the existing clinical practice culture where SSC is not integrated, the lack of appropriate medical practitioner competency, or environmental barriers such as lack of practical arrangements to ensure that the mother’s clothes are conveniently arranged. Enablers of the ideal action will involve the education program focusing on postpartum mothers.


Bigelow, A. E., & Power, M. (2020). Mother–infant skin-to-skin contact: Short‐and long-term effects for mothers and their children born full-term. 
Frontiers in Psychology
11, 1–9.

Brimdyr, K., Cadwell, K., Svensson, K., Takahashi, Y., Nissen, E., & Widström, A. M. (2020). The nine stages of skin‐to‐skin: Practical guidelines and insights from four countries. 
Maternal & Child Nutrition
16(4), 1–8.

Ghaedrahmati, M., Kazemi, A., Kheirabadi, G., Ebrahimi, A., & Bahrami, M. (2017). Postpartum depression risk factors: A narrative review. 
Journal of Education and Health Promotion
6, 1–7.

Turenne, J. P., Héon, M., Aita, M., Faessler, J., & Doddridge, C. (2016). Educational intervention for an evidence-based nursing practice of skin-to-skin contact at birth. 
The Journal of Perinatal Education
25(2), 116-128.

Widstrom, A. M., Brimdyr, K., Svensson, K., Cadwell, K., & Nissen, E. (2019). Skin‐to‐skin contact the first hour after birth, underlying implications and clinical practice. 
Acta Paediatrica
108(7), 1192-1204.

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