Early skin-to-skin contact for mothers and their healthy newborn infants
Data were scarce to assess the effect of early skin-to-skin contact on breastfeeding up to 4-6 and 12 months of life. However, the review found that skin-to-skin contact between the mother and her baby immediately after birth reduces crying, improves mother-infant interaction, keeps the baby warm, and helps the mother to breastfeed successfully. No important negative effects were identified.
RHL Commentary by Puig G, Sguassero Y
1. EVIDENCE SUMMARY
Ideally, early skin-to-skin contact (SSC) begins immediately after birth by placing the naked newborn baby prone on the mother’s bare chest. This practice based on intimate contact within the first hours of life may facilitate maternal-infant behaviour and interactions through sensory stimuli such as touch, warmth, and odour. Moreover, SSC is considered a critical component for successful breastfeeding initiation.
Based on these premises, the updated version of this review aimed at assessing randomized controlled trials (RCTs) or quasi-RCTs about the effect of early SSC starting within the first 24 hours of life versus routine neonatal care in both healthy full-term and late preterm babies (i.e., 34-37 weeks’ gestational age). The principal outcome of interest was breastfeeding. New outcomes were added in this update of the review, e.g., maternal bonding behaviours and maternal psychological changes after SSC that were explored by observation or by applying questionnaires/subscales of maternal-infant bonding, and infant physiological adaptation.
Regarding the intervention, three categories of early SSC were considered by the authors: a) in birth SSC (during the first minute of life), b) very early SSC (beginning at 30-40 minutes after birth), and c) early SSC (anytime between 1 and 24 hours after birth)
The search methods for identifying relevant studies included two independent searches conducted in MEDLINE by the Cochrane Pregnancy and Childbirth Group and the Cochrane Neonatal Group. In this regard, no databases relevant for developing countries such as Latin American and Caribbean Literature and African Index Medicus were explored. Additional efforts were done by hand searching more than twenty pertinent journals. No language restrictions were applied.
Three main quality criteria were applied: 1) allocation concealment (adequate, unclear or inadequate), 2) completeness of follow-up, and 3) blinding of participants, caregivers and outcome assessors.
Overall, thirty trials were included (twenty-nine were RCTs). The majority of the included studies were conducted in developed countries such as USA, UK, Canada and Sweden. Eight studies were conducted in developing countries. Only four studies conducted in the USA, South Africa and Taiwan involved preterm babies.
Early skin-to-skin contact varied largely across studies in terms of timing and duration. For example, in some study settings the intervention could not begin immediately after birth because of hospital policy and duration ranged from 15 minutes to a mean of 48 hours of continuous SSC. These factors precluded the authors from pooling the results.
Sixty-four clinical outcomes were reported. It is important to highlight that only twenty were measured in more than one study and that not all the reported outcomes were relevant to poor countries. For breastfeeding outcomes (the most commonly reported) comparison of early SSC (n= 70/74) versus standard contact (n= 54/75) showed a positive effect on breastfeeding at discharge hospital (odds ratio [OR] 6.35, 95% confidence interval [CI] 2.15 to 18.71). However, this result should be interpreted with caution due to small sample sizes that are reflected by the wide confidence intervals.
When considering long-term impact on breastfeeding (e.g., 1-4 months), results from 10 studies involving 552 mothers-healthy term infants pairs showed also a positive impact (OR: 1.82, 95% CI: 1.08 to 3.07, I2 = 41.2%). Again this result should be interpreted with caution because the confidence intervals are showing imprecision.
Data were scarce to assess the effect on breastfeeding up to 4-6 and 12 months of life, maternal outcomes in terms of satisfaction, self-confidence status and maternal parenting confidence. Nevertheless, according to the review findings, skin-to-skin contact between mother and babies after birth reduces crying, improves mother-infant interaction, keeps the baby warmer, and helps mothers to breastfeed successfully. Furthermore, on a positive note, no important negative effects were identified.
2. RELEVANCE TO UNDER-RESOURCED SETTINGS
2.1. Magnitude of the problem
Each year, new scientific and epidemiological evidence contributes to our knowledge of breastfeeding's role in the survival, growth, and development of a child as well as the health and well-being of a mother.1 Current breastfeeding patterns are still far from the recommended level and considerable variation exists across regions.2
Extra tactile, odour, and thermal cues provided by skin-to-skin contact may stimulate babies to initiate breastfed more successfully. So, this practice should be seen as a beneficial, low cost, and feasible intervention to promote lactation after delivery especially in settings that lack sanitation and safe water where breastfeeding can be life saving. In addition, a recent study conducted in Ghana3, demonstrated that the promotion of early initiation of breastfeeding has the potential to make a major contribution to the achievement of the child survival millennium development goal; 16% of neonatal deaths could be saved if all infants were breastfed from day 1 and 22% if breastfeeding started within the first hour.
2.2. Applicability of the results
It is not easy to extrapolate the results of the review to poor countries, since the review is largely based on studies carried out in well-resourced settings where contextual factors such as cultural beliefs and lack of accessibility to basic health care may not be seen as major barriers to support exclusive breastfeeding. In this regard, to develop and implement long-term breastfeeding early support systems is considered a major challenge in developing countries.
2.3. Implementation of the intervention
Early SSC should be considered as a routine health care intervention after delivery both in developed and developing country settings. However, the implementation of this intervention requires further considerations in under-resourced communities. On one hand, factors such as room temperature, lack of privacy/space, overcrowding, etc., may interfere with its potential benefits and, on the other hand, the situation is often worsened by inaccurate medical advice from health workers who lack proper skills and training in early breastfeeding support starting with early skin-to-skin contact.
Practices such as how infants are handled after birth are part of institutional functioning, and may not be easy to change. For example, the current practice at Maternidad Martin in Rosario (Argentina), with 4000 deliveries per year, is to place the newborn prone on the mother’s bare abdomen for one minute while it is smoothly dried with a blanket. It is worth pointing out that this new practice has been recently introduced following the implementation of delayed cord clamping intervention.4, 5 In this scenario, SSC starts immediately after birth but it lasts only 1-3 minutes. Thus, prolonging the duration of the SSC as part of routine practice for early breastfeeding support could be easy to implement, especially in Baby Friendly Hospitals.6
Appropriate definition of SSC is a priority for future research taking into account specific timing, frequency and duration of intervention. As neonates tend to be more alert within the first two hours of life, this should be considered a convenient period for initiating successful mother and child interaction. Well-conducted RCTs are warranted to demonstrate the real impact of early SSC on maternal and infant health, including preterm babies and mothers who deliver by caesarean section and in different settings (developed and developing countries).
Sources of support: Centro Rosarino de Estudios Perinatales, Rosario, Argentina.
- The Pan American Health Organization. Quantifying the benefits of breastfeeding: a summary of the evidence. Washington, D.C.: PAHO © 2002.
- Web site: http://www.childinfo.org (acceded 17 August 2007)
- Edmond KM, Zandoh C, Quigley MA, Amenga-Etego S, Owusu-Agyei S, Kirkwood BR. Delayed breastfeeding initiation increases risk of neonatal mortality. Pediatrics, 2006;117(3):e380-6.
- Ceriani Cernadas JM, Carroli G, Pellegrini L, Otano L, Ferreira M, Ricci C, Casas O, Giordano D, Lardizabal J. The effect of timing of cord clamping on neonatal venous hematocrit values and clinical outcome at term: a randomized, controlled trial. Pediatrics. 2006 Apr;117(4):e779-86.
- Ceriani Cernadas, JM, Carroli G, Lardizabal J. The effect of timing of cord clamping on neonatal venous hematocrit values and clinical outcome at term: a randomized, controlled trial. In reply, Pediatrics, 2006,118:3,1317-1319
- World Health Organization. Evidence for the ten steps to successful breastfeeding. Geneva: The Organization; 1998. Web site:www.who.int/child-adolescent-health/New_Publications/NUTRITION/WHO_CHD_98.9.pdf (accessed 6 Sept 2007).
This document should be cited as: Puig G, Sguassero Y. Early skin-to-skin contact for mothers and their healthy newborn infants: RHL commentary (last revised: 9 November 2007). The WHO Reproductive Health Library; Geneva: World Health Organization.