Early skin-to-skin contact for mothers and their healthy newborn infants
Early skin-to-skin contact appears to offer some clinical benefit, particularly for breastfeeding. Supportive policies, but few additional resources, will be needed in hospitals and birthing centres to help implement this intervention, which might be regarded as "natural".
RHL Commentary by Saloojee H
1. EVIDENCE SUMMARY
Early skin-to-skin contact (SSC) involves placing the naked newborn prone on the mother's bare chest at birth or soon afterwards (within 24 hours of birth). Although from an evolutionary perspective skin-to-skin contact is the norm, separating the newborn from its mother soon after birth is common practice in many settings. The aim of this review was to examine the effects of early skin-to-skin contact on breastfeeding exclusivity and duration, and maternal–infant behaviour and physiology.
Thirty studies involving 1925 participants (mother-infant pairs) met the inclusion criteria. Of these, 29 were randomized controlled trials and one quasi-randomized. None met all of the reviewers’ methodological quality criteria. The overall quality of the included studies was considered “marginally adequate”. The two most problematic areas were allocation concealment (implementation of random allocation sequence without foreknowledge of intervention assignments) and provider performance bias (the delivery and postpartum staff could be aware of the group assignment of the mothers). In only eight trials was allocation to groups adequately concealed from the investigators.
There were important variations between studies in how the intervention was implemented and in their measured outcomes. Both these variations seriously limited the ability of the reviewers to conduct meta-analysis of the data. This is a critical impediment to developing sound practical recommendations on this topic. For example, duration of SSC ranged from approximately 15 minutes to 48 hours of continuous contact. Although 64 clinical outcomes were assessed, only 20 were measured by more than one study, and only three outcomes were evaluated in five or more studies.
The review found statistically significant and positive effects of early (anytime between one and 24 hours postbirth) skin-to-skin contact on continuation of breastfeeding at one to four months postbirth (10 trials; 552 participants) (odds ratio [OR] 1.82, 95% confidence interval [CI] 1.08 to 3.07), There was also a trend towards improved breastfeeding duration (seven trials; 324 participants) (weighted mean difference (WMD) 42.55 days, 95% CI -1.69 to 86.79). The review also demonstrated statistically significant benefits of early SSC on the maintenance of infant temperature in the neutral thermal range, infant crying, infant blood glucose, and summary scores of maternal affectionate love/touch, and attachment behaviour, during observed breastfeeding within the first few days postbirth. Late preterm infants had better cardio-respiratory stability with early SSC.
While there were no demonstrably significant clinical or statistical differences identified for many infant physiological and attachment outcomes, no important negative effects of early SSC were identified.
The review includes studies published up to May 2006. Recent work has explored the effects of SSC provided by fathers on crying and prefeeding behaviour in healthy, full-term infants born by elective caesarean birth (1) and described improved sucking competency in newborns offered early SSC (2). Possible negative consequences (e.g. bradycardia and desaturation) of SSC have also been evaluated.
2. RELEVANCE TO UNDER-RESOURCED SETTINGS
2.1. Magnitude of the problem
The predominant outcome investigated by most studies in this review was breastfeeding practice. Globally, poor breastfeeding practices, including low initiation rates, short exclusive breastfeeding periods and early termination of breastfeeding are recognized problems. Databases reporting on international breastfeeding trends are available online (3, 4) In general, while breastfeeding initiation rates in most developing countries exceed 90% (5), the major difficulty is maintaining exclusive breastfeeding for six months, with about 35% of infants being exclusively breastfed between 0–4 months of age in the 94 countries monitored by the WHO Global Data Bank on Breastfeeding (3). The highest levels occur in East Asia and the Pacific (6). On a positive note, many mothers continue to breastfeed after the first year of life in under-resourced countries. Global levels of continued breastfeeding have increased and are relatively high (79%) at one year of age, and around half of all infants are still breastfeeding at two years of age (6).
2.2. Applicability of the results
The studies were conducted in diverse populations in North America, Europe, Asia, South America and southern Africa. However, three-quarter (23/30) of the studies appear to have been conducted among well-resourced participants and settings. All but four of the 30 studies enrolled healthy full-term infants.
It is difficult to extrapolate the results of this review to particularly under-resourced settings, since the review is based on studies that were mostly conducted in well-resourced, developed-world settings. Parents’ decisions about breastfeeding are influenced by a complex interplay of factors including geographical setting (country, urban/rural), cultural beliefs, available resources, underlying disease (e.g. HIV) and educational status, among others. One therefore wonders what the relative contribution of SSC might be in a multivariate analysis of determinants of breastfeeding practice where other determinants such as cultural beliefs or socio-demographic status are included.
None of the studies included in the review provided data about how many infants in the SSC group were breastfed or how effectively they were nursed while the intervention was being offered. It is debatable if it would be possible to replicate the breastfeeding benefits described in the review (e.g. number of women still breastfeeding at 1–3 months, or duration of breastfeeding) in cohorts of women from under-resourced setting where >90% of mothers would be expected to initiate and continue breastfeeding for the first three months of life.
A more pertinent outcome, in poorer settings would be the ability of the intervention to contribute to exclusive breastfeeding rates at four to six months postbirth. Only one of the included studies provided data on this topic.
Similarly, it is difficult to extrapolate the maternal–infant bonding data to under-resourced and global settings. Importantly, two studies included in the review involving impoverished women had statistically significant differences in affectionate contact behaviours favouring the SSC contact group.
2.3. Implementation of the intervention
Based on the available evidence, SSC appears to offer some clinical benefit, particularly for breastfeeding. The positive results in this review were obtained in diverse (mainly well-resourced) countries and among women of low and high socioeconomic class.
The ability and enthusiasm to introduce SSC will vary in different settings. Supportive policies are needed in hospitals and birthing centres to help facilitate early initiation of SSC. Practices such as how infants are handled after birth are well entrenched as part of institutional functioning, and may not be easily amenable to change. It may also be necessary to inform midwives of the benefits of SSC since SSC to facilitate breastfeeding initiation is not well promoted in most midwifery textbooks (7). Finally, mothers may need to be encouraged to overcome their hesitation to place the baby in SSC for a prolonged period in hot and humid conditions. Overcrowding, lack of privacy and maternal modesty may also hinder the use of SSC in some units.
On the other hand, the intervention requires few additional resources and promotes a practice that might be regarded as "natural". In some settings, postpartum labour ward practices (e.g. cleaning and measurement of the baby, assistance with breastfeeding and repair of episiotomy) often interfere with the first contact between the mother and the infant (8). Even in busy units, supervision of this activity (SSC) requires minimal additional time and should be able to take precedence over other hospital routines. The timing of the intervention may be important because most infants are very alert in the first two hours post-birth and, if undisturbed and unmedicated, will self-attach correctly to the nipple in the first hour.
Another development that is likely to ease the introduction and acceptance of SSC as a routine for all healthy full-term infants is the increasing use of kangaroo mother care (which includes SSC as one component) in many units caring for low-birth-weight infants.
Somewhat more difficult to provide consistently in a labour ward or birthing unit in under-resourced settings is initial breastfeeding assistance (particularly for primiparous women), a component of the intervention that has been associated with greater success. Effective suckling may be a critical component of SSC with regards to long-term breastfeeding success. Negative cultural ideas about colostrum abound in different settings globally and may be a significant barrier to early initiation of breastfeeding. Similarly, mothers who are HIV positive may elect to offer SSC to their infant, but may opt out of offering the breast to suckle if they have chosen to formula-feed.
Further primary research is warranted to provide more convincing evidence of the value of this intervention. This is particularly necessary since the methodological quality of the included studies was only "marginally adequate", the characteristics of the SSC and control conditions were diverse, and many outcome measures were difficult to combine.
Questions requiring further research include:
- What is the influence on breastfeeding outcomes of the timing (how soon after birth), dose (for how long), and components offered (e.g. suckling) of the intervention?
- What is the effect of early SSC on mothers who deliver by caesarean section?
- How do term and preterm infants differ when both are offered the intervention?
- How do the health-care providers view (attitudes and responses, including resistance) the implementation of this intervention?
- How do mothers view the intervention and what is their level of satisfaction with the intervention in the context of the overall birth experience (using qualitative methods)?
All of the above questions are as relevant in well-resourced settings as they are in under-resourced settings. However, it is likely that results will vary in different settings, even within districts in a region, depending on how the intervention is introduced and implemented.
Sources of support: Nil
- Erlandsson K, Dsilna A, Fagerberg I, Christensson K. Skin-to-skin care with the father after cesarean birth and its effect on newborn crying and prefeeding behavior. Birth 2007; 34(2):105-114.
- Moore ER, Anderson GC. Randomized controlled trial of very early mother-infant skin-to-skin contact and breastfeeding status. J Midwifery Womens Health 2007; 52(2):116-125.
- Global Data Bank on Breastfeeding. URL: http://www.who.int/nut/db_bfd.htm (accessed 16 Sept 2005).
- UNICEF Global Database. Breastfeeding indicators. Available at: http://www.childinfo.org/eddb/brfeed/test/database.htm (accessed 16 Sept 2005).
- La Leche League International Center for Breastfeeding Information. Breastfeeding statistics. Schaumburg, IL, USA. Available at: http://www.lalecheleague.org/cbi/bfstats03.html (accessed 16 Sept 2005).
- UNICEF. End decade databases. Breastfeeding. Available at: http://www.childinfo.org/eddb/brfeed/index.htm (accessed 16 Sept 2005).
- Cooke M, Cantrill R, and Creedy D. The first breastfeed: a content analysis of midwifery textbooks. Breastfeed. Review 2003;11:5–11.
- Awi DD and Alikor EA. The influence of pre- and post-partum factors on the time of contact between mother and her new-born after vaginal delivery. Nigeria Journal of Medicine 2004;13:272–275.
This document should be cited as: Saloojee H. Early Early skin-to-skin contact for mothers and their healthy newborn infants: RHL commentary (last revised: 4 January 2008). The WHO Reproductive Health Library; Geneva: World Health Organization.