The Magic and the Mystery of Skin-to-Skin
I meant to do skin-to-skin with Cee after her birth, I swear. It was in my birth plan. But after a long labor, Cee was born blue and limp, and the understandable concern about her health trumped any ideas I’d had about optimizing our postpartum experience. Cee was whisked away to a warmer on the other side of the room and encircled by the NICU team. Thankfully, I heard her cry within a few moments, and she was in my arms soon after. But by then, she was wrapped in a pink and blue flannel blanket, and I was too overwhelmed and taken with her to think of unwrapping her. Instead, I held her, and we gazed into each other’s eyes. She started rooting and was nursing within a couple of minutes. It was a magical first meeting, and it wasn’t until later that I realized that I’d screwed up and forgotten to do skin-to-skin.
I’ve been researching this topic for a chapter in my book about the postpartum period. I’m writing about what we know and don’t know about getting to know our newborns, establishing breastfeeding, rooming in, and yes, skin-to-skin. When I started working on this chapter, I thought the skin-to-skin thing was a slam-dunk, maybe even too obvious to be of much interest to my readers.
Modern-day interest in skin-to-skin, also called kangaroo care, began in 1978 in the NICU at San Juan de Dios hospital in Bogotá, Columbia. For every 10 premature babies born there, only 3 survived. There weren’t enough incubators or nurses. Babies were tucked two to three at a time in incubators, and infections were rampant. Parents weren’t encouraged to be involved in the babies’ care, and having little emotional connection to them, many abandoned their sickly babies at the hospital. Kangaroo care was a desperate attempt to care for these vulnerable babies. Mothers were essentially asked to be their babies’ incubators, holding them skin-to-skin 24 hours per day and breastfeeding on demand.
The results were astounding. The kangaroo care babies in Bogotá grew well, were more likely to be breastfed, and were less likely to get severe infections or be abandoned. The power of kangaroo care for low birth weight babies has since been confirmed in multiple studies. A 2011 Cochrane review concluded that skin-to-skin helps stabilize premature newborns, reduces mortality, infections, hypothermia, and length of stay in the hospital. These benefits are particularly clear in developing countries, but many hold in industrialized nations as well.
With the impressive success of skin-to-skin care for preemies, it seemed natural to assume that full term babies would benefit from it as well. But the research in this area is disappointing. Much of it is of poor methodological quality, made more complex by the fact that you can’t blind study participants to whether they received skin-to-skin or “usual care.” There’s no placebo for skin-to-skin. And “usual care” varied tremendously, depending on whatever was the protocol in that time and place, and trust me, there have been a lot of weird ideas about how to treat newborns.
Let me give you a few examples. These studies are often cited as providing evidence that skin-to-skin contact is essential for helping newborns transition to the outer world:
1. A 1990 Swedish study by Righard and Alade, published in the prestigious medical journal The Lancet, concluded that babies that had one hour of uninterrupted skin-to-skin with mom immediately after birth had better breastfeeding “technique.” Of 38 skin-to-skin babies, 24 had good technique at the first feed. In the control group, the babies were held by mom for 20 minutes, then taken away for some routine procedures in the delivery room for another 20 minutes, and then returned to mom. Of the 34 infants in the separation group, only 7 were deemed to have good breastfeeding technique. But there are two HUGE, unfortunate holes in this study design: it wasn’t randomized and it wasn’t blinded. The mothers and their midwives decided whether they should be in the skin-to-skin group or the control/separation group. Can you see the problem with this? Might there be some other factors at play here, things that could be different between moms who say, “Yes, absolutely, I want to hold my baby!” or those who say, “Eh, you can take her for a while,” or those who are simply too exhausted to care? And might the investigators, judging the babies’ sucking technique, possibly be biased towards which group they think should be better feeders? These are big problems, and quite frankly, they make this study useless. And yet, it’s cited all the time.
2. In Christensson et al. 1992, 50 mothers giving birth at a Madrid hospital were randomized to skin-to-skin or separate care groups. The skin-to-skin group had 90 minutes of skin contact after birth, and compared to the control babies, they did better in lots of ways. They were warmer, had lower respiration rates and higher blood glucose, and they cried less. But how were the control babies treated? They were tucked into a hospital bassinette and then LEFT THERE for 90 minutes. The control parents were explicitly asked NOT to pick up or feed their babies. So of course the control babies didn’t do very well! Since their parents were forbidden to soothe them, they cried more, breathed faster, and burned away their blood glucose under that stress. It made me angry to read this study; it’s unethical and wouldn’t be allowed today. And it tells us nothing about how babies do when they are wrapped in a blanket and held, or placed in a bassinette but picked up for comforting and feeding.
3. Finally, there’s this fascinating study conducted in Japan in 2002 and published by Mizuno et al. in 2007. In this study, 30 newborns had 50 minutes of skin-to-skin and a chance to breastfeed right after birth, and the control group was given “usual care.” What was usual care at this hospital? NO contact with the mother for 24 hours after birth. Mom basically got to say, “Hi, baby!” and was then instructed to rest for the next day while baby stayed in the nursery and was fed formula. After that first day, baby roomed in with mom and breastfed on schedule every 3 hours. Importantly, the skin-to-skin babies also followed usual care after their 50-minute snuggle and chance to breastfeed.
The babies were then tested at 1 and 4 days of age to see which smells they preferred – mom’s breast milk, another woman’s milk, formula, orange juice or water. (Picture paper towels soaked in each of these liquids, suspended above baby’s head. Whichever one baby spent more time smacking her lips at was deemed the preferred smell.) In both groups of babies, breast milk was preferred on day 1, but they didn’t differentiate between their mother’s milk and that of a stranger. On day 4, the skin-to-skin babies had a preference for their own mother’s milk, but the control babies still didn’t seem to differentiate their mom’s milk from the stranger’s. The skin-to-skin babies were also breastfed longer (about 7 months) compared with the control babies (about 5 months).
The results of this study are kind of cool, and they fit with other research that shows that babies have a heightened sense of smell in the hour or so after birth. And the differences in breastfeeding duration were impressive. But again, like the Christenson study, the experimental paradigm of 24 hours of separation is just so strange. This was just a decade ago, folks. (I have no idea if this practice is common in Japan today.) Regardless, this study tested the effects of complete mom/baby separation with near-complete separation, and thankfully, neither situation is relevant to parents giving birth in even the least-progressive hospitals in the U.S. today.
I chose these three studies because they illustrate the problems with skin-to-skin research, but they aren’t unique. A 2012 Cochrane review of skin-to-skin for healthy babies (i.e., not preemies) included 34 studies (including the second and third described above) but noted that NONE of them met Cochrane’s criteria for methodological quality. The main problems cited were the risk of bias and the variability in protocols for what it meant to have skin-to-skin or “usual care,” as illustrated in the above studies. Despite these problems, the review authors went ahead with a slew of meta-analyses. They did find a small but significant improvement in the number of skin-to-skin dyads breastfeeding between 1 and 4 months of age compared with the controls. However, there wasn’t evidence that skin-to-skin improved the success of the first breastfeed, the number of moms exclusively breastfeeding at discharge from the hospital, or the number of babies still breastfeeding at one year. The results are rather wishy-washy with lots of warnings not to put much stock in them due to small sample sizes and high variability.
Well, I felt discouraged after reading all these studies. I was really hoping to come out of my research with a sort of evidence-based protocol for a happy postpartum experience. Instead, I was beginning to feel like the emphasis on skin-to-skin contact for full term babies has been sort of overblown. I know that sounds crazy, and believe me, I don’t want to be the party-pooper who ruins something as sweet as mother and babe, skin against skin, in the first moments of life outside the womb. But I’ve read study after study on skin-to-skin, and there’s no getting around it: the science just isn’t that good.
What I learned, more than anything, was that it was impossible to look at this science without becoming entangled in history and culture. These studies, conducted over the last several decades, tell a story of where we have come from. We’ve come from an era of over-medicalized childbirth, in which women were largely removed from the process of childbirth and from caring for their babies in the postpartum. Babies were whisked off to nurseries, thought to be better for infection control (they weren’t), only having short visits with mom for scheduled feedings. In the 1970’s and 80’s, with a growing appreciation for the value of breastfeeding and the parent-infant bond, moms pushed for more mother-infant contact, skin-to-skin, breastfeeding on demand, and rooming in. There are likely many reasons why these changes were really good for families, but they are surprisingly difficult to tease apart in the studies. And like the studies I described above, where usual care was maternal deprivation, they don’t mean much to us now.
I thought it might help me sort this out to look further into the past, to try to understand how families welcomed babies before obstetricians and hospitals came onto the scene. I had this idea that surely uninterrupted skin-to-skin contact was the universal postpartum routine of our ancestors. But I was wrong here, too. A survey of anthropological records of non-industrial societies, going all the way back to 1750 B.C., found that skin-to-skin contact after birth was observed in only 14% of them. If there was anything universal about their postpartum practices, it was that most bathed both mom and baby soon after birth (surprising to me), and most babies stayed in a quiet room with their mothers for a few days or a week after birth.
So what does this all mean to today’s parents, seeking a meaningful postpartum experience? To me, it means that the postpartum can’t be reduced to a list of optimal practices, like boxes to be checked. We absolutely should be able to hold our babies and to keep them close as we get to know one another. That should be facilitated and encouraged in all birth settings. If we learn anything from these weird studies, it’s stuff we probably already knew: don’t leave your newborn in a bassinette to cry, and don’t wait 24 hours to try breastfeeding for the first time. Do snuggle your baby, feed her, and soothe her when she cries. Do know that you are important to your baby, and that this is just the beginning of a long and beautiful relationship. Skin-to-skin may help with all of this, but do it because it feels good, not because you think it’s scientifically proven or the natural way of our ancestors.
It also helps to remember that we humans are extraordinarily flexible animals. Sometimes childbirth is scary and traumatic, and rarely is it predictable. It’s been like that throughout the course of human history, and it will always be that way to some degree. One thing that worries me when we start talking about the “optimal” childbirth and postpartum experience is that when things don’t go as planned, moms might feel like they failed their babies in some way. But if mom can’t hold the baby, for whatever reason, then dad, other mom, auntie, friend, grandpa, doula, midwife, or nurse can take over. What’s important is for baby to be cared for by responsive caregivers. There is not a magical formula for that. It is just about families being with babies.
I’ve been reading too many studies on this topic, and I’m ready to hear some real-life stories! What was your postpartum experience like? Did you do skin-to-skin, and if so, do you think it was helpful? What else helped ease your transition to parenthood and your baby’s transition to the outside world?