Immediate skin-to-skin contact after a very preterm birth : supporting the parent-infant relationship

Background: Preterm birth poses challenges that may negatively affect parental mental health and infant development. A well-functioning parent-infant relationship can mitigate the risk of preterm birth on infant development, and early interventions that foster close parent-infant contact and support parenthood from birth are therefore warranted. Skin-to-skin contact between parents and infants has been found to decrease distress in parents and improve parent-infant interaction behaviors, yet little is known regarding its benefits when initiated immediately after birth for more vulnerable infants. Further, there is a lack of knowledge regarding the difference in effects of SSC provided during the first postnatal hours and later in the neonatal period. The overall aim of this thesis was to gain knowledge about, and a deeper understanding of, the impact of skin-to-skin contact between parents and very preterm infants when practiced immediately after birth, as compared to later in the neonatal period, on parents’ mental health and the parent-infant relationship within the first year of life.

Methods: The four studies in this thesis derive from two multicenter studies: a prospective longitudinal study, “The 2nd International Closeness Survey” (study I) and a randomized clinical trial, “The Immediate Parent-Infant Skin-to-Skin Study” (IPISTOSS) (study II-IV). Study I involved mothers (n=684) and fathers (n=574) to preterm infants born less than 35 gestational weeks of age from 23 neonatal units in 15 countries. In study I, associations between the amount of proximity between parents and infants in the neonatal unit, including time spent in skin-to-skin contact, and parents’ symptoms of depression (assessed with Edinburgh Postnatal Depression Scale, EPDS) at discharge and at 4 months were investigated. Study II-IV derived from the randomized controlled trial IPISTOSS that compared care in skin-to-skin contact immediately after birth with standard incubator care for very preterm infants (28–33 gestational weeks of age) in three neonatal units in Sweden and Norway. Study II included 73 parent couples to 91 infants and investigated the effect on parents’ symptoms of depression (EPDS) and anxiety (assessed with Spielberger State-Trait Anxiety Inventory, STAI) within the infants’ first year of life. Study III included 71 infants and their 56 mothers and investigated the effect on mother-infant interaction quality (measured with the Parent-Child Early Relational Assessment, PCERA) at 4 months. In study IV, 12 parents participated in individual interviews at the time of discharge to home to explore their experiences of immediate skin-to-skin contact and the care and support from healthcare staff.

Results: Study I found no association between the duration of parent-infant proximity in the neonatal unit and symptoms of depression in parents at discharge and at 4 months. Study II found that immediate skin-to-skin contact after a very preterm birth decreased EPDS scores in mothers (mean [SD] 9.8 [6.0] vs 12.3 [5.9] in the control group, p <0.05) at one week after birth and EPDS (mean [SD] 3.0 [2.0] vs 6.4 [4.7] in the control group, p=0.02) and STAI scores (mean [SD] 27.7 [5.7] vs 36.1 [9.5] in the control group, p=0.002) in fathers at term-equivalent age of the infant. In study III, immediate skin-to-skin contact was found to enhance the infants’ expressions of positive affect, communication and social skills when interacting with their mothers at 4 months (PCERA subscale 3 score mean [SD] 3.60 [0.47] vs 3.27 [0.50] in the control group, p=0.01). In study IV, immediate skin-to-skin contact was described as an empowering experience that promoted feelings of connectedness with their newborns yet had challenges and required adequate support from healthcare staff.

Conclusion: The main findings in this thesis suggest that the practice of skin-to-skin contact in the immediate postpartum period has an impact on the early parent-infant relationship following a very preterm birth, which is supported by the positive influence of immediate skin-to-skin contact on parents’ mental health and mother-infant interaction quality as well as by parents’ experiences. Beyond the immediate postpartum period, parent-infant proximity and skin-to-skin contact in the NICU need to be continued to be supported, along with other elements within infant- and family-centered developmental care that may further contribute to parental mental health after a preterm birth

List of scientific papers

I. Lehtonen L, Lilliesköld S, De Coen K, Toome L, Gimeno A, Caballero S, Tameliene R, Laroche S, Retpap J, Grundt H, Van Hoestenberghe MR, Skene C, Pape B, Axelin A, Separation, Closeness Experiences in Neonatal Environment (SCENE) research group. Parent-infant closeness after preterm birth and depressive symptoms: A longitudinal study. Frontiers in Psychology. 2022; 22;13:906531.
https://doi.org/10.3389/fpsyg.2022.906531

II. Lilliesköld S, Lode-Kolz K, Rettedal S, Westrup B, Bergman N, Sorjonen K, Ådén U, Mörelius E, Jonas W. Skin-to-skin contact at birth for very preterm infants and symptoms of depression and anxiety in parents during the first year: A secondary outcome of a randomized clinical trial. [Manuscript]

III. Lilliesköld S, Lode-Kolz K, Rettedal S, Lindstedt J, Linnér A, Markhus Pike H, Ahlqvist-Björkroth S, Ådén U, Jonas W. Skin-toskin contact at birth for very preterm infants and mother-infant interaction quality at 4 months: A secondary analysis of the IPISTOSS randomized clinical trial. JAMA Network Open. 2023; 6(11): e2344469.
https://doi.org/10.1001/jamanetworkopen.2023.44469

IV. Lilliesköld S, Zwedberg S, Linnér A, Jonas W. Parents' experiences of immediate skin-to-skin contact after the birth of their very preterm neonates. Journal of Obstetric, Gynecological & Neonatal Nursing. 2022; 51(1): 53-64.
https://doi.org/10.1016/j.jogn.2021.10.002