Pronurturance at birth and risk of postpartum haemorrhage: biology, theory and new evidence

Background: In spite of the almost universal adoption of the active management of the 3rd stage of labour, postpartum haemorrhage (PPH) rates continue to rise; reaching 19% or more in some obstetric units. Conversely, there is emerging evidence that women who experience continuity of midwifery care have lower rates of PPH. Continuity of midwifery care normally includes immediate skin-to-skin contact and early breastfeeding in the 3rd and 4th stages of labour to optimise release of endogenous oxytocin. The objective was to determine if skin-to-skin contact and breastfeeding at birth affected the rate of early PPH in a group of mixed risk Australian women. Method: De-identified birth records (N=11,219) for the calendar years 2009 and 2010 were extracted from the electronic ObstetriX database which records public sector births in New South Wales, Australia. Excluded (n = 3,671) were all cases where skin-to-skin and breastfeeding immediately after birth was not possible leaving 7,548 cases for analysis. The outcome measure was PPH of 500 ml or more; the independent variables were ‘skin-to-skin contact’ and ‘breastfeeding’ at birth (the combination of these two variables I ultimately termed pronurturance). Analyses were conducted to determine the risk of PPH for women who experienced skin-to-skin contact and breastfeeding at birth in the 3rd and 4th stages of labour compared with those women who did not (regardless of the woman’s risk status or mode of birth). Results: Women who experienced skin-to-skin contact and breastfeeding at birth had an almost fourfold decrease in risk of PPH, (OR 0.26, 95% CI 0.20-0.33, p \u3c 0.001). After adjustment for covariates women who experienced skin-to-skin contact and breastfeeding at birth were again less likely to have a PPH (OR 0.55, 95% CI 0.41-0.72, p \u3c 0.001). This protective effect of ‘pronurturance’ on PPH held true in sub-analyses for both women at ‘lower’ risk (OR 0.22, 95% CI 0.17-0.30, p \u3c 0.001) and ‘higher’ risk (OR 0.37, 95% CI 0.24-0.57, p \u3c 0.001) of PPH. Conclusion: These results suggest that skin-to-skin contact and breastfeeding in 3rd and 4thstages of labour was effective in reducing the risk of PPH in a group of mixed risk Australian women. The explanation of this finding is that skin-to-skin contact and breastfeeding promote optimal endogenous oxytocin release. Skin-to-skin contact and breastfeeding at birth has shown no known negative effects and should be encouraged for all women during 3rd and 4th stage labour care