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Abstract
A total of 69 trials involving 7290 mother-infant pairs were analyzed to evaluate the effects of immediate skin-to-skin contact on breastfeeding and physiological outcomes.
- Immediate skin-to-skin contact probably increases rates of exclusive breastfeeding at hospital discharge and up to six months postbirth.
- Infants with immediate skin-to-skin contact may have improved blood glucose levels.
- Skin-to-skin contact is associated with higher infant axillary temperatures, although the clinical significance is uncertain.
- The impact of skin-to-skin contact on maternal placental separation time and postpartum blood loss appears inconclusive.
- The evidence regarding infant physiological stabilization, measured by the SCRIP score, indicates potential benefits but is based on small sample sizes.
Simplified
RATIONALE: Research supports the beneficial effects of immediate maternal-infant skin-to-skin contact (SSC) after all modes of birth on breastfeeding/lactation and neonatal physiology, but little is known about how it might influence maternal physiology, including postpartum blood loss and placental separation time. Despite the findings from the 2016 Cochrane review of skin-to-skin contact, and although the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) recommend immediate, continuous, uninterrupted SSC after birth, newborn infants are still separated from their mothers during this period in many settings. SSC is less common in low-income and lower-middle-income countries (World Bank classification), which suggests country income level could impact breastfeeding exclusivity. This update integrates the evidence found since 2015 into the review.
OBJECTIVES: To assess the effects of immediate skin-to-skin contact (< 10 minutes postbirth) or early skin-to-skin contact (10 minutes-24 hours postbirth) compared with existing hospital practices (standard contact) on the establishment and maintenance of breastfeeding and on maternal and infant physiology among healthy newborn infants and their mothers.
SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, and CINAHL up to 22 March 2024 and two trial registers up to 3 July 2025, along with reference checking and contact with experts.
ELIGIBILITY CRITERIA: Randomized controlled trials that compared immediate or early SSC with other hospital care after a vaginal or cesarean birth. Participants were mothers and their healthy full-term or late preterm newborns (≥ 34 weeks' gestation). Infants admitted to the neonatal intensive care unit were excluded.
OUTCOMES: Our critical outcomes included exclusive breastfeeding, infant axillary temperature, infant blood glucose levels, infant SCRIP score (cardiorespiratory stability), placental separation time/duration of the third stage of labor, and maternal blood loss.
RISK OF BIAS: We used Cochrane's original risk of bias 1 tool (RoB 1). We assessed the risk of performance and detection bias separately for subjective and objective outcomes.
SYNTHESIS METHODS: We conducted random-effects meta-analysis where there was substantial heterogeneity and fixed-effect meta-analysis for infant blood glucose and SCRIP score. We calculated the summary risk ratio (RR) and 95% confidence interval (CI) using the Mantel-Haenszel method for dichotomous outcomes. We calculated the mean difference (MD) and 95% CI using inverse variance for continuous outcomes, except infant SCRIP score, where we used the standardized mean difference (SMD). We used the GRADE approach to summarize the certainty of evidence.
INCLUDED STUDIES: We added 26 new trials (3775 mother-infant pairs) to this update for a total of 69 trials (7290 mother-infant pairs). Most studies (43/69) compared immediate SSC with standard hospital care. Ten studies included late preterm infants, and 15 included children born by cesarean delivery. Thirty-two trials were conducted in high-income countries, 25 in upper-middle-income countries, and 12 in lower-middle-income countries. Fifty-six studies contributed data to the meta-analyses. No included trial met all the criteria for high-quality methodology and reporting. Many analyses had statistical heterogeneity due to considerable differences between SSC and control group conditions.
SYNTHESIS OF RESULTS: Breastfeeding/lactation SSC compared with standard contact probably increases rates of exclusive breastfeeding at hospital discharge to one month postbirth (RR 1.36, 95% CI 1.19 to 1.56; I² = 62%; 12 studies; 1556 mother-infant pairs; moderate-certainty evidence) and at six weeks to six months postbirth (RR 1.38, 95% CI 1.09 to 1.74; I² = 87%; 11 studies; 1135 mother-infant pairs; moderate-certainty evidence), though both analyses had substantial heterogeneity. Infant physiological stability SSC compared with standard contact probably increases infant axillary temperature, but the MD of 0.28 °C is not clinically meaningful (MD 0.28, 95% CI 0.14 to 0.41; I² = 95%; 11 studies; 1349 infants; moderate-certainty evidence). SSC probably increases blood glucose levels measured in mg/dL (MD 10.49, 95% CI 8.39 to 12.59; I² = 0%; 3 studies; 114 infants; moderate-certainty evidence). Infants who have SSC may also have higher SCRIP scores overall, indicating more optimal cardiorespiratory stabilization. However, the trials reporting this outcome had small sample sizes, and the clinical significance was unclear because trialists reported averages of multiple time points (SMD 1.24, 95% CI 0.76 to 1.72; I² = 0%; 2 studies; 81 infants; low-certainty evidence). Maternal physiology SSC may result in little to no difference in placental separation time/duration of the third stage of labor in minutes (MD -2.26, 95% CI -5.04 to 0.52; I² = 88%; 4 studies; 450 mothers; low-certainty evidence) and maternal postpartum blood loss in mL (MD -145.92, 95% CI -416.96 to 125.11; I² = 97%; 2 studies; 143 mothers; very low-certainty evidence), although these results should be interpreted with caution due to high heterogeneity and the small number of studies.
AUTHORS' CONCLUSIONS: This review supports immediate SSC after birth, regardless of mode of birth, for mothers and their healthy full-term and late preterm infants in middle-income and high-income countries. No included studies were conducted in low-income countries. SSC probably promotes exclusive breastfeeding and improves infant thermoregulation and blood glucose levels. In addition, SSC may increase infant stabilization measured by the SCRIP score. The evidence about maternal physiological outcomes was inconclusive. Future research should prioritize methodological rigor. This includes providing clear descriptions of interventions and standard contact, carefully selecting relevant outcomes, and using reliable and objective measurement tools. Understudied areas include: the impact of medications and anesthetics, in terms of dose-response and other variables during SSC; biological and psychosocial mechanisms; additional physiological effects of SSC; and longer-term impacts. Instances of harm should be recorded. As WHO/UNICEF recommends immediate, uninterrupted SSC as the standard of care, randomizing to separation of mother and newborn may no longer be justifiable.
FUNDING: This Cochrane review had no dedicated funding.
REGISTRATION: Review Update (2016) https://doi.org/10.1002/14651858.CD003519.pub4 Review Update (2012) https://doi.org/10.1002/14651858.CD003519.pub3 Review Update (2007) https://doi.org/10.1002/14651858.CD003519.pub2 Original review (2003) https://doi.org/10.1002/14651858.CD003519 Protocol (2002) DOI unavailable.