Journal of Preventive Medicine

Introduction
Skin-to-skin contact between mother and baby has proven benefits for both of them such as maintaining optimal body temperature for the baby, early initiation of breastfeeding, continuation of exclusive feeding with breast milk after discharge, increasing breastfeeding self-efficacy, facilitating the early exit of the placenta, reducing the maternal stress, and strengthening the mother-child bond. Action is needed to achieve World Health Organization (WHO)’s goal of reducing infant mortality to 12 per 1,000 live births by 2030. Making skin-to-skin contact between mother and baby immediately after birth is one of the necessary measures to reduce the mortality of mothers and babies. Considering the importance of skin-to-skin contact between mother and baby in the first hour of birth and its positive effects on the baby’s health, evaluating how to implement this process is necessary as a vital step to improve the quality of maternity healthcare services. In this regard and considering the unavailability of information about the implementation of skin-to-skin contact instructions between mother and baby in Zanjan, Iran, the present study aims to determine the factors predicting the performance of health workers in Ayatollah Mousavi Hospital in Zanjan City in the implementation of skin-to-skin contact and the initiation of breastfeeding within the first hour after birth in women gave birth.

Methods
This descriptive-cross-sectional study was conducted in 2022 on 99 health workers in the maternity block, operating room and postpartum ward of Ayatollah Mousavi Hospital in Zanjan City who were selected by census method and 386 mothers gave birth at this hospital who were selected by a systematic random sampling method. The data was collected using a questionnaire surveying demographic characteristics in mothers (age, educational level, method of delivery, baby’s sex, place of residence, baby’s weight) and health workers (age, work experience, marital status, employment status, position, work department).
 The performance of health workers in the implementation of the guidelines for skin-to-skin contact between mother and baby and initiation of breastfeeding within the first hour after birth was assessed using self-assessment method and an interview with mothers. The data were presented using descriptive statistics and chi-square test was used to examine the difference in the performance of health workers based on demographic variables. Multiple linear regression analysis with stepwise method was used to determine the predictors of health workers’ performance.

Results
Health workers’ self-evaluation of their performance showed that nearly 48% had moderate performance and 32.3% had good performance. Evaluation of health workers’ performance through interviews with mothers showed that more than 40% of mothers perceived their performance as good. The results of the chi-square test showed that mothers who had higher educational level and those were trained by the health workers perceived the good performance of the health workers with a higher percentage (P=0.001). The results of linear regression showed that working in the maternity block was significantly related to the good performance of health workers (β=0.24, P=0.001).
 This means that health workers who serve in the maternity block were more likely to have better performance in the implementation of skin-to-skin contact and initiation of breastfeeding within the first hour after birth by 24%. Moreover, non-participation in the training course was associated with a decrease in performance (β=-0.65, P=0.001), meaning that health workers who did not participate in the training course were more likely to have a lower performance by 65%. The coefficient of determination (R²) for this regression model was 0.50, indicating that 50% of the changes in health workers’ performance are explained by the work department and history of participation in the training course. 
The results of Stepwise regression model showed that mothers with a university education were more likely to perceive health workers’ performance as good by 22% (β=0.22, P=0.001). Also, mothers who did not receive training were less likely to perceive health workers’ performance as good by 20% (β=-0.20, P=0.001). 

Conclusion
This study shows that the health workers’ performance in implementing the skin-to-skin contact instructions and initiating breastfeeding within the first hour after birth was at a relatively favorable level, but it is far from the ideal level. To improve their practice, it is recommended to conduct continuous training courses focusing on the importance of skin-to-skin contact and breastfeeding, especially for new employees. Also, considering the relationship of some demographic characteristics of mothers with their perceptions, it is recommended to design and provide them with special educational materials related to the importance and method of establishing skin-to-skin contact with the baby, especially for mothers with low education. For a better conclusion, it is recommended to conduct more studies in private hospitals or other public hospitals.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by Ethics Committee of Zanjan University of Medical Sciences, Zanjan, Iran (Code: IR.ZUMS.REC.1401.278).

Funding
This study was taken from the general practitioner thesis of Ahmadreza Zabihi, approved by the Faculty of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran.

Authors' contributions
Conceptualization, visualization, methodology, and supervision: Nahid Jafari and Azam Maleki; Software and formal analysis: Azam Maleki; Validation, resources, project administration, and funding acquisition: Nahid Zafari; Investigation: Ahmadreza Zabihi; Data curation: Robab Bayat; Writing the original draft: Aida Ghaffari; Review and editing: Aida Ghaffari, and Azam Maleki.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors appreciate the Computer Service Consulting for the Staff of the Clinical Research Development Unit at Ayatollah Mousavi Hospital, Zanjan University of Medical Sciences, Zanjan, Iran.


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