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Facilitating “instant and overwhelming love” should be standard midwifery care

Skin-to-skin contact between a mother and baby at birth

While facilitating immediate and uninterrupted skin-to-skin (S2S) for an hour after birth should be routine care, in most health services it is not. Having a baby in naked body contact with their mother immediately after birth has significant benefits for both. Immediate and sustained S2S (60 minutes or more) offers women physiological benefits including lower risk of postpartum haemorrhage (Saxton et al., 2015). Significantly, S2S increases the chance of having an effective first breastfeed, exclusively breastfeeding at hospital discharge, and sustained breastfeeding up to four months postpartum (Moore et al., 2016). Importantly, S2S offers psychological benefits too including lower symptoms of postpartum anxiety and depression (Kirca et al., 2021). Early S2S strengthens the mother-infant relationship, increases parental confidence, and initiates caregiving behaviours (Bystrova et al., 2009). Women’s experiences of S2S at birth have been summed up as feeling “instant and overwhelming love” (Anderzén-Carlsson et al., 2014). Despite endorsement by the World Health Organization, there has been a significant lag between evidence about S2S and translation into routine midwifery practice (Widström et al., 2019).

Australian women’s experiences of the first few hours after birth

Transforming Maternity Care Collaborative’s Dr Jyai Allen will present findings from an Australia women’s survey at the International Confederation of Midwives Virtual Congress in June 2021. Survey items drew on concepts from two midwifery theories: Birth Territory (Fahy & Parratt, 2006) and Pronurturance (Fahy et al., 2015). The survey link was shared widely on birth and parenting social media groups. The survey was open to women who had given birth in the previous 3-years in any Australian birth setting (hospital, birth centre, home). The main outcome for the study was ‘pronurturance’ defined as immediate S2S (within 1-minute of birth), uninterrupted holding for 60 minutes, and breastfeeding in the birth setting. Statistical testing identified that mode of birth and model of care were the factors that had a significant impact on pronurturance.

Most surveyed women did not experience ‘pronurturance’

Of the 1200 respondents, only 22% experienced all the elements of pronurturance (Allen et al., 2019a). Lack of pronurturance was because:

25% did not have an immediate cuddle

30% did not have any S2S

66% did not hold their baby for at least 60-minutes

19% did not breastfeed in the birth setting.

Women who were aware of the benefits of S2S, were more likely to receive it. Women who did not receive S2S were either wearing clothing that impeded it (60%) or received the baby  wrapped or dressed (40%) (Allen et al., 2019a). Most women (70%) said they would have removed their top / bra if the midwife had suggested it. When the first cuddle was ended before 60-minutes, 80% of women reported that was the choice of staff. The most common reasons were non-urgent: perform a procedure on the mother, weigh the baby, get the woman to shower (Allen et al., 2019a).

What hinders and what helps?

When surveyed women had a known midwife at birth, they were 89% more likely to get pronurturance. High workloads in fragmented models result in “time poverty” which limits the time midwives spend on the psycho-social-emotional elements of birth (Boyle et al. 2016). Whereas in the M@NGO trial, women allocated to midwifery continuity of carer were more likely to perceive their antenatal visits were unhurried and that they had time to ask questions (Allen et al., 2019b). During birth, midwifery continuity models provide explicit support for physiological birth (Kemp & Sandall, 2010), which includes undisturbed third and fourth stages of labour (Fahy et al., 2015). Whereas midwives working shifts are more likely to prioritise institutional needs and less likely to advocate for women they do not know (Finlay & Sandall, 2009).

Surveyed women who had a caesarean section were 93% less likely to receive pronurturance (Allen et al. 2019). We know that women who have a caesarean section commonly have a delay before their first cuddle, are less likely to have S2S, and less likely to breastfeed in the first hour after birth (Stevens et al., 2018). Importantly, however, women who have a caesarean section are more likely to benefit from S2S in terms of birth satisfaction (Kahalon et al., 2021). Changing practice around the time of caesarean section is hard. An implementation study showed that even after a 4-month period of staff education and agreed changes to practice, the increase in S2S contact for 15-minutes in the operating room only moved from 20 to 25 percent (Thompson et al., 2021).

Midwives can make a big difference – but they need support

Midwives and midwifery students are best placed to facilitate immediate and uninterrupted S2S after birth to initiate bonding and breastfeeding. That said, in operating theatre, having a multi-disciplinary team who understand the benefits of S2S and breastfeeding – and actively support it – is crucial to practice change (Thompson, 2021).

Midwives can make a difference by:

  1. Talking to women during pregnancy about the benefits of S2S and how to achieve it
  2. Helping women to remove bras or tops just prior to birth
  3. Assisting women to place the naked baby S2S against her bare chest and keeping baby warm with towels/blankets
  4.  Supporting delayed cord clamping and not separating babies from their mothers (Mejía Jiménez et al., 2021)

Furthermore, health services should prioritise embedding evidence-based practice into routine maternity care. This means identifying and strategically addressing the institutional processes that interrupt mothers and babies in the first hour after birth.

References

Highlighted research:  Allen, J., Parratt, J. A., Rolfe, M. I., Hastie, C. R., Saxton, A., & Fahy, K. M. (2019a). Immediate, uninterrupted skin-to-skin contact and breastfeeding after birth: A cross-sectional electronic survey. Midwifery, 79, 102535-102535. https://doi.org/10.1016/j.midw.2019.102535

Anderzén-Carlsson, A., Carvalho Lamy, Z. & Eriksson, M. (2014) Parental experiences of providing skin-to-skin care to their newborn infant—Part 1: A qualitative systematic review. International Journal of Qualitative Studies on Health and Well-being, 9(1). https://doi.org/10.3402/qhw.v9.24906

Allen, J, Kildea, S, Tracy, MB, Hartz, DL, Welsh, AW, Tracy, SK. (2019b). The impact of caseload midwifery, compared with standard care, on women’s perceptions of antenatal care quality: Survey results from the M@NGO randomized controlled trial for women of any risk. Birth, 46, 439– 449.

Bystrova, K., Ivanova, V., Edhborg, M., Matthiesen, A-S, Ransjo-Arvidson, A-B, Mukhamedrakhimov, R., Uvnas-Moberg, K., Widstrom, A-M. (2009). Early contact versus separation: effects on mother-infant interaction one year later. Birth, 36(2), 97–109.

Fahy, K., Saxton, A., Smith, L., & Campbell, F. (2015). Making pronurturance routine care to reduce PPH: Practice development research. Women and Birth, 28, S45. https://doi.org/10.1016/j.wombi.2015.07.144

Fahy, K. M., & Parratt, J. A. (2006). Birth Territory: A theory for midwifery practice. Women Birth, 19(2), 45-50. https://doi.org/10.1016/j.wombi.2006.05.001

Kahalon, R., Preis, H., & Benyamini, Y. (2021). Who benefits most from skin-to-skin mother-infant contact after birth? Survey findings on skin-to-skin and birth satisfaction by mode of birth. Midwifery92, 102862. https://doi.org/10.1016/j.midw.2020.102862

Kemp, J., & Sandall, J. (2010). Normal birth, magical birth: the role of the 36-week birth talk in caseload midwifery practice. Midwifery, 26(2), 211-221. https://doi.org/10.1016/j.midw.2008.07.002

Kirca, N, Adibelli, D. Effects of mother–infant skin-to-skin contact on postpartum depression: A systematic review. (2021). Perspectives in Psychiatric Care. 1– 10.

Mejía Jiménez, I., Salvador López, R., García Rosas, E., Rodriguez de la Torre, I., Montes García, J., de la Cruz Conty, M. L., Martínez Pérez, O., & Spanish Obstetric Emergency Group† (2021). Umbilical cord clamping and skin-to-skin contact in deliveries from women positive for SARS-CoV-2: a prospective observational study. BJOG128(5), 908–915. https://doi.org/10.1111/1471-0528.16597

Saxton, A., Fahy, K., Rolfe, M., Skinner, V. & Hastie, C. (2015). Does skin-to-skin contact and breast feeding at birth affect the rate of primary postpartum haemorrhage: results of a cohort study. Midwifery, 31(11), 1110-1117. https://doi.org/10.1016/j.midw.2015.07.008

Stevens, J., Schmied,V., Burns, E., & Dahlen, H.G. (2018). Who owns the baby? A video ethnography of skin-to-skin contact after a caesarean section. Women and Birth, 31(6), 453-462. https://doi.org/10.1016/j.wombi.2018.02.005

Thompson, N. M., & Maeder, A. B. (2021). Initiative to increase skin-to-skin contact in the operating room after cesarean. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 50(2), 193–204. https://doi.org/10.1016/j.jogn.2020.10.008

Widström, 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 Paediatrica108(7), 1192–1204. https://doi.org/10.1111/apa.14754