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Parents’ Experiences of Immediate Skin-to-Skin Contact After the Birth of Their Very Preterm Neonates

Open AccessPublished:November 09, 2021DOI:https://doi.org/10.1016/j.jogn.2021.10.002

      Abstract

      Objective

      To explore parents’ experiences of immediate skin-to-skin contact after the birth of their very preterm neonates and their perceptions regarding care and support from staff.

      Design

      A descriptive qualitative study.

      Setting

      Birth and neonatal units within a university hospital in Sweden.

      Participants

      Six parent couples who co-cared for their very preterm neonates with skin-to-skin contact throughout the first 6 hours after birth.

      Methods

      We analyzed individual interviews using reflexive thematic analysis as described by Braun and Clarke.

      Results

      The parents’ experiences of immediate skin-to-skin contact with their very preterm neonates were represented by the following three themes: A Pathway to Connectedness, Just Being in a Vulnerable State, and Creating a Safe Haven in an Unknown Terrain. Skin-to-skin contact helped the parents attain their roles as essential caregivers and provided a calming physical sensation that promoted parents’ feelings of connectedness with their newborns. When parents provide skin-to-skin contact at birth, staff members need to recognize and address their vulnerability. A good relationship with nursing staff, which was mediated through staff behaviors and availability, facilitated skin-to-skin contact.

      Conclusion

      Skin-to-skin contact initiated at birth with very preterm neonates was a valuable and empowering experience for parents and enhanced early bonding between parents and their newborns. Staff members should recognize that skin-to-skin contact between parents and neonates is an interactive process that has challenges and requires adequate support. Future research is warranted to understand the needs of nursing staff who provide initial care in the postpartum period. Furthermore, we recommend the implementation of maternal–neonatal couplet care.

      Keywords

      Globally, every year, approximately 15 million neonates are born preterm at less than 37 weeks gestation, and many neonates require hospital care (
      • Chawanpaiboon S.
      • Vogel J.P.
      • Moller A.-B.
      • Lumbiganon P.
      • Petzold M.
      • Hogan D.
      • Gülmezoglu A.M.
      Global, regional, and national estimates of levels of preterm birth in 2014: A systematic review and modelling analysis.
      ). The admission of a newborn to a NICU can be a traumatic experience for parents and often involves parent–newborn separation, which impairs the early processes of becoming a parent (
      • Flacking R.
      • Lehtonen L.
      • Thomson G.
      • Axelin A.
      • Ahlqvist S.
      • Moran V.H.
      SCENE Group
      Closeness and separation in neonatal intensive care.
      ). An infant- and family-centered developmental care approach, which supports infant neurobiology and development and acknowledges the vital importance of parent–infant attachment for long-term child health (
      • Roué J.-M.
      • Kuhn P.
      • Lopez Maestro M.
      • Maastrup R.A.
      • Mitanchez D.
      • Westrup B.
      • Sizun J.
      Eight principles for patient-centred and family-centred care for newborns in the neonatal intensive care unit.
      ), is recommended in NICUs today. The first hours after birth have been described as a unique and sensitive period during which this relationship can be established when parents and newborns are kept in close proximity to each other (
      • Bergman N.J.
      Birth practices: Maternal-neonate separation as a source of toxic stress.
      ;
      • Widström A.M.
      • Brimdyr K.
      • Svensson K.
      • Cadwell K.
      • Nissen E.
      Skin-to-skin contact the first hour after birth, underlying implications and clinical practice.
      ).
      Nurturing care, a framework used to promote early childhood development, was recommended by the World Health Organization (
      World Health Organization & United Nations Children’s Fund
      Nurturing care for every newborn.
      ). Nurturing care is defined as the provision of a stable environment that is sensitive to children’s needs and opportunities for interactions that are emotionally supportive and developmentally stimulating (
      • Britto P.R.
      • Lye S.J.
      • Proulx K.
      • Yousafzai A.K.
      • Matthews S.G.
      • Vaivada T.
      • Bhutta Z.A.
      Nurturing care: Promoting early childhood development.
      ). A stable environment for the newborn has been suggested to involve direct skin-to-skin contact (SSC) with a parent from birth onward (
      • Bergman N.J.
      Birth practices: Maternal-neonate separation as a source of toxic stress.
      ). SSC offers the expected evolutionary environment for development and a “buffering protection of adult support” (
      • Bergman N.J.
      Birth practices: Maternal-neonate separation as a source of toxic stress.
      , p. 1087), which is especially needed by neonates born preterm. In this context, SSC is a place of care rather than the care itself, and the roles of both parents are emphasized.
      Skin-to-skin contact involves placing the naked newborn prone on the parent’s bare chest. In a high-tech NICU environment, SSC is often practiced intermittently as part of the routine care practice for stable preterm neonates (
      • Nyqvist K.H.
      • Anderson G.C.
      • Bergman N.
      • Cattaneo A.
      • Charpak N.
      • Widström A.M.
      Expert Group of the International Network on Kangaroo Mother Care
      State of the art and recommendations. Kangaroo mother care: Application in a high-tech environment.
      ). Skin-to-skin contact provided immediately after birth supports the newborn’s physiologic transition from intrauterine to extrauterine life, including adjustments in temperature, heart rate, and respiration, and promotes parent–infant bonding (
      • Gupta N.
      • Deierl A.
      • Hills E.
      • Banerjee J.
      Systematic review confirmed the benefits of early skin-to-skin contact but highlighted lack of studies on very and extremely preterm infants.
      ). Skin-to-skin contact at birth has mostly been studied after the birth of healthy term or late preterm neonates. For example, women’s experiences of SSC at birth with their full-term neonates included moments of happiness and closeness (
      • Leblanc N.
      • Pelletier J.
      Early skin-to-skin contact with full-term newborns: The personal experience of first-time parents.
      ), which start a positive spiral of mutual interactions (
      • Dalbye R.
      • Calais E.
      • Berg M.
      Mothers’ experiences of skin-to-skin care of healthy full-term newborns—A phenomenology study.
      ). In a seminal study with full-term infants, a sustained positive influence of SSC at birth on mother–infant interactions was observed at 1 year of age (
      • Bystrova K.
      • Ivanova V.
      • Edhborg M.
      • Matthiesen A.-S.
      • Ransjö-Arvidson A.-B.
      • Mukhamedrakhimov R.
      • Widström A.-M.
      Early contact versus separation: Effects on mother-infant interaction one year later.
      ). Skin-to-skin contact has also been described by parents of preterm neonates as a particularly important first-time event after birth (
      • Baylis R.
      • Ewald U.
      • Gradin M.
      • Nyqvist K.H.
      • Rubertsson C.
      • Blomqvist Y.T.
      First-time events between parents and preterm infants are affected by the designs and routines of neonatal intensive care units.
      ). In a recent study by
      • Mehler K.
      • Hucklenbruch-Rother E.
      • Trautmann-Villalba P.
      • Becker I.
      • Roth B.
      • Kribs A.
      Delivery room skin-to-skin contact for preterm infants—A randomized clinical trial.
      , SSC between women and neonates born at 25 to 32 weeks gestation that was initiated directly in the birth room compared with later in the NICU lowered the risk of early postpartum depression and improved the quality of mother–infant interaction at 6 months corrected age. Skin-to-skin contact immediately or as soon as possible after birth was recommended for preterm neonates in need of intensive care (
      • Nyqvist K.H.
      • Anderson G.C.
      • Bergman N.
      • Cattaneo A.
      • Charpak N.
      • Widström A.M.
      Expert Group of the International Network on Kangaroo Mother Care
      State of the art and recommendations. Kangaroo mother care: Application in a high-tech environment.
      ). However, most data confirming the benefits of SSC provided immediately after birth are from term or late preterm neonates, and studies in which researchers focused on preterm neonates of lower gestational ages (GAs) are lacking (
      • Gupta N.
      • Deierl A.
      • Hills E.
      • Banerjee J.
      Systematic review confirmed the benefits of early skin-to-skin contact but highlighted lack of studies on very and extremely preterm infants.
      ). In clinical practice, most frequently, parents are still not allowed to hold their very or extremely preterm neonates immediately after birth. This may be explained by differences in staff experiences of supporting SSC in the physical environment and the timing and initiation of SSC (
      • Blomqvist Y.T.
      • Ewald U.
      • Gradin M.
      • Nyqvist K.H.
      • Rubertsson C.
      Initiation and extent of skin-to-skin care at two Swedish neonatal intensive care units.
      ). Furthermore, staff may not recognize SSC at birth as a feasible option in relation to the newborn’s medical condition and care or may be concerned about how SSC will be tolerated by parents at this time.
      Parents’ experiences of skin-to-skin contact immediately at the birth of their very preterm neonates have not been extensively described.
      During recent years, the GA at which SSC is considered best practice at birth has been decreasing.
      • Kristoffersen L.
      • Stoen R.
      • Hansen L.F.
      • Wilhelmsen J.
      • Bergseng H.
      Skin-to-skin care after birth for moderately preterm infants.
      found that immediate SSC starting in the birth room was feasible and safe for moderately preterm neonates (GA = 32–34 weeks).
      • Dahlø R.H.
      • Gulla K.
      • Saga S.
      • Kristoffersen L.
      • Eilertsen M.-E.B.
      Sacred hours: Mothers’ experiences of skin-to-skin contact with their infants immediately after preterm birth.
      reported that mothers believed that this practice enhanced bonding and normalized the birth experience. In our previous study (
      • Linnér A.
      • Klemming S.
      • Sundberg B.
      • Lilliesköld S.
      • Westrup B.
      • Jonas W.
      • Skiöld B.
      Immediate skin-to-skin contact is feasible for very preterm infants but thermal control remains a challenge.
      ), immediate SSC at birth for very preterm neonates (GA = 28–33 weeks) was also feasible, although we did not examine parents’ experiences.
      • Maastrup R.
      • Weis J.
      • Engsig A.B.
      • Johannsen K.L.
      • Zoffmann V.
      ‘Now she has become my daughter’: Parents’ early experiences of skin-to-skin contact with extremely preterm infants.
      described parents’ early experiences of SSC with more fragile neonates as a process that moved from initial ambivalence to an appreciation of SSC as beneficial for the parent and the newborn.
      • Anderzén-Carlsson A.
      • Lamy Z.C.
      • Eriksson M.
      Parental experiences of providing skin-to-skin care to their newborn infant—Part 1: A qualitative systematic review.
      identified a supportive environment as important for parents’ willingness and ability to practice SSC. Such an environment includes staff who are encouraging and accessible and provide practical assistance with SSC.
      • Bergman N.J.
      Birth practices: Maternal-neonate separation as a source of toxic stress.
      stressed the importance of keeping parents and preterm neonates together in SSC from birth and gradually implementing care routines and competencies in the NICU to support this. When examining the benefits of SSC at birth for preterm neonates of lower GAs, understanding parents’ experiences of immediate SSC within the context in which it is given to support and increase its dissemination in clinical practice is crucial. For very preterm neonates, initial stabilization and care in an incubator are still the norm. Therefore, parents’ experiences of holding a very preterm neonate in SSC at birth have not been examined in comparison with their experiences of SSC as routine practice in the NICU once the very preterm neonate is medically stabilized. Thus, our aim in the present study was to explore parents’ experiences of immediate SSC after the birth of their very preterm neonates and their perceptions regarding care and support from staff.

      Methods

       Design

      This study was part of the Immediate Parent–Infant Skin-to-Skin Study (IPISTOSS), a randomized controlled trial on various aspects of immediate SSC between parents and very preterm neonates after birth (
      • Linnér A.
      • Westrup B.
      • Lode-Kolz K.
      • Klemming S.
      • Lilliesköld S.
      • Markhus Pike H.
      • Jonas W.
      Immediate parent-infant skin-to-skin study (IPISTOSS): Study protocol of a randomised controlled trial on very preterm infants cared for in skin-to-skin contact immediately after birth and potential physiological, epigenetic, psychological and neurodevelopmental consequences.
      ). For the present study, we used a descriptive qualitative design with an inductive approach and a reflexive thematic analysis as described by
      • Braun V.
      • Clarke V.
      Using thematic analysis in psychology.
      ,
      • Braun V.
      • Clarke V.
      Reflecting on reflexive thematic analysis.
      . Reflexive thematic analysis is an analytic approach that offers theoretical flexibility and emphasizes subjectivity as a resource and the analytic process as active and generative. We chose this design because it is well suited for finding in-depth descriptions of experiences previously unexplored. The study was situated within a constructionist framework in which meaning and experience were understood as being co-constructed in and between individuals and societies through lived experiences and interactions with others (
      • Denzin N.K.
      • Lincoln Y.S.
      The SAGE handbook of qualitative research.
      ). This framework was suitable for our study because relational perspectives are predominant within an infant- and family-centered care approach, guiding the NICU sociocultural context. The Swedish Ethical Review Authority granted ethical approval for our study.

       Setting

      We conducted the study in the birth and neonatal units at a university hospital in Stockholm, Sweden. In this setting, SSC is actively promoted during the NICU stay and initiated for very preterm neonates when considered medically acceptable (e.g., usually from hours to days from birth).

       Participants

      In conjunction with participation in the IPISTOSS, recruitment for the present study was conducted during a 12-month period (2018–2019). In the IPISTOSS, neonates born at 28 0/7 to 32 6/7 gestational weeks were considered very preterm. Purposive sampling was performed in which parents who were randomized to the IPISTOSS intervention group of immediate SSC were asked to participate in an interview regarding their experiences. The purposive sampling criteria included variations in women’s and men’s experiences, neonatal GA, and mode of birth. All participants had the ability to speak Swedish or English. The sample size was based on the concept of information power as described by
      • Malterud K.
      • Siersma V.D.
      • Guassora A.D.
      Sample size in qualitative interview studies: Guided by information power.
      and determined within the process of data collection. Thus, sample size was ultimately determined by the adequacy, that is, the richness and complexity, of the data for addressing the aim (
      • Braun V.
      • Clarke V.
      To saturate or not to saturate? Questioning data saturation as a useful concept for thematic analysis and sample-size rationales.
      ).

       Procedures

      Within the IPISTOSS, SSC with either parent was initiated in the birth room and continued in the neonatal unit throughout the first 6 hours after birth for those allocated to the intervention group. In the case of a cesarean birth, the partner was the first to provide the SSC because the mother needed postoperative care. Mobile respiratory support and equipment for monitoring enabled stabilization of the newborn in the birth unit and during transport to the NICU with SSC. Skin-to-skin contact was interrupted only for procedures such as endotracheal intubation or placement of umbilical catheters, as further described in our study protocol (
      • Linnér A.
      • Westrup B.
      • Lode-Kolz K.
      • Klemming S.
      • Lilliesköld S.
      • Markhus Pike H.
      • Jonas W.
      Immediate parent-infant skin-to-skin study (IPISTOSS): Study protocol of a randomised controlled trial on very preterm infants cared for in skin-to-skin contact immediately after birth and potential physiological, epigenetic, psychological and neurodevelopmental consequences.
      ).
      Interviews were performed approximately 1 to 2 weeks after discharge from the hospital, allowing parents to gain some perspective. However, the time since birth ranged from 3 to 9 weeks (M = 4.8 weeks, SD = 2.3). The interviews were held in the hospital or in participants’ homes. All interviews were conducted individually except one that was held with both parents. The interviews were recorded and transcribed verbatim by the first author (S.L.), a pediatric nurse with work experience in the NICU and researcher in the IPISTOSS. The interviews lasted between 17 and 51 minutes (M = 33.3 minutes, SD = 9.3). We developed a semistructured interview guide to explore participants’ experiences with the first SSC with their newborns. All interviews started with the question, “Can you tell me about when your son/daughter was born and the first hours surrounding the birth?” This initial question was followed by questions such as “If you focus on the moment when you had skin-to-skin contact with your baby, can you describe how this felt for you?”, “How did the staff support you during skin-to-skin contact at this time point?”, and “How has skin-to-skin contact within the first hours following birth affected your experience of becoming a parent?” The questions were open ended, and we further explored participants’ developing accounts using probing questions and questions that encouraged reflection and thought.

       Analysis

      The analysis followed six phases in a recursive and reflexive manner (
      • Braun V.
      • Clarke V.
      Using thematic analysis in psychology.
      ,
      • Braun V.
      • Clarke V.
      One size fits all? What counts as quality practice in (reflexive) thematic analysis?.
      ). In phase one, the first (S.L.) and second authors (S.Z.) acquainted themselves with the data by reading and discussing the interviews and taking notes of initial impressions and ideas of potential meaning and patterns. In the second phase, S.L. coded the entire data set inductively. Each code represented a singular idea in accordance with its relevance to the aim of the study. S.L. started with a more semantic coding (capturing the more explicit content) and then moved toward a more latent coding (capturing the implicit meanings), which was reflective of the data as located within a social context (e.g., the social context of childbirth). In the third through fifth phases, S.L. continued with theme development. This was an active process of examining, combining, and clustering codes together into bigger or more meaningful patterns identified across the data set, visualized through a thematic map that was developed throughout this process. S.L. reviewed the initial themes recursively for their robustness in relation to the coded data, data set, and study aim. We constructed themes through the coding and theme development process, and we aimed at capturing patterns of shared meaning that were united by a central organizing idea (
      • Braun V.
      • Clarke V.
      Reflecting on reflexive thematic analysis.
      ). In the last phase, S.L. developed a figure that further synthesized the findings to a comprehensive whole. S.L. performed the analysis, and S.Z. helped develop and refine the analysis in an ongoing reflective discourse throughout the process. The constructionist perspective offered an interpretative lens throughout the analysis when reflecting on the meaning of the parents’ experiences.

       Trustworthiness

      Credibility, transferability, dependability, and confirmability were addressed to ensure trustworthiness (
      • Guba E.G.
      Criteria for assessing the trustworthiness of naturalistic inquiries.
      ), and we used a checklist of criteria for thematic analysis (
      • Braun V.
      • Clarke V.
      Using thematic analysis in psychology.
      ). We addressed credibility through the prolonged and recursive engagement with the data and thoughtfulness and reflection about the data (
      • Braun V.
      • Clarke V.
      One size fits all? What counts as quality practice in (reflexive) thematic analysis?.
      ) using a reflexive audit trail (documenting the various steps in the analysis process, including the researcher’s reflective notes) and peer debriefing sessions throughout the analysis process. We addressed transferability by using purposive sampling and providing clinical, sociodemographic, and contextual information of the participants. To strengthen dependability, the same researcher conducted, transcribed, and coded all the interviews. Nuances in coding and interpretation were then discussed with the second author, an experienced qualitative researcher who was also familiar with the raw data set. To enhance confirmability, we used illustrative data extracts with the findings to provide sufficient evidence of the themes within the data.

      Results

      During the period of recruitment to the present study, we randomized 12 parent couples to the intervention group in the IPISTOSS, and six couples (i.e., six women and six men) participated in the study. These parents had SSC with their newborns within 6 hours after birth, except for one participant who had SSC shortly thereafter. The clinical and sociodemographic characteristics of the parents and neonates are shown in Table 1.
      Table 1Sociodemographic and Clinical Characteristics of Participants
      Characteristicsn (%)Mean (SD)
      Parents (n = 12)
       Parental age, years33.2 (4.2)
       Education
      Completed university5 (41.6)
      Completed high school7 (58.4)
      Women (n = 6)
       Prior birth2 (33.3)
       Cesarean birth4 (66.6)
       Preeclampsia2 (33.3)
       Prelabor rupture of membranes4 (66.6)
      Neonates (n = 7)
       Singletons5 (71.4)
       Twins2 (28.6)
       Gestational age, weeks31.5 (1.1)
       Birth weight, g1,490.7 (475.9)
       Apgar score at 5 minutes6.7 (2.7)
       CPAP, nasogastric tube, and peripheral line during first 6 hours7 (100)
       Central line and need of radiography during first 6 hours1 (14.3)
      Duration of SSC 0–6 hours after birth
       SSC duration for men,
      One father initiated SSC shortly after 6 hours postbirth and was not included in the calculation.
      minutes
      187.5 (51.8)
       SSC duration for women, minutes132.9 (108.9)
       SSC duration for neonates, minutes293.6 (70.3)
      Note. CPAP = continuous positive airway pressure; SSC = skin-to-skin contact.
      a One father initiated SSC shortly after 6 hours postbirth and was not included in the calculation.
      We constructed three themes based on the analysis of the data as follows: A Pathway to Connectedness, Just Being in a Vulnerable State, and Creating a Safe Haven in an Unknown Terrain. The themes were further defined through eight subthemes, and each subtheme provided a distinct aspect of the main theme (see Table 2). Furthermore, we constructed a figure to combine the three themes and present the why (the purpose), what (the conditions), and how (the means) to understand and support SSC between parents and their very preterm neonates at birth (see Figure 1).
      Skin-to-skin contact at birth engages parents in their parenting role in a meaningful way and enhances their early connectedness with their newborns.
      Table 2Themes Representing Participants’ Experiences of Skin-to-Skin Contact and Support From Staff in the First Hours After the Birth of a Very Preterm Neonate
      ThemeSubtheme
      A Pathway to ConnectednessSkin-to-Skin Contact as a Positive Sign
      A Calming Physical Sensation
      Building Confidence Over Time
      Just Being in a Vulnerable StatePhysical and Mental Readiness
      Presence: Easy and Hard
      A Person With Own Needs
      Creating a Safe Haven in an Unknown TerrainStaff Behavior Is Key
      Providing a Sense of Availability
      Figure thumbnail gr1
      Figure 1Synthesis of the purpose (why), conditions (what), and means (how) for understanding and supporting skin-to-skin contact between parents and their very preterm neonates at birth.

       Theme 1: A Pathway to Connectedness

      This theme described SSC as an intervention that enabled participants to actively participate and feel significant during the care of their newborns. Parenthood and early interaction were strengthened by the physical sensations of directly feeling and seeing the newborn and experiencing a need for closeness with the newborn. The following three subthemes provided distinct aspects of this main theme: Skin-to-Skin Contact as a Positive Sign, A Calming Physical Sensation, and Building Confidence Over Time.

       Skin-to-Skin Contact as a Positive Sign

      As part of this first subtheme, participants elaborated on what meaning they ascribed to the experience of SSC. For example, they saw SSC as a positive signal that set them on a path to become closer to their newborns. For the participants, being in SSC with their newborns meant that the newborn was doing well, which resulted in feelings of relief and happiness in that moment. Skin-to-skin contact as a positive signal could further be given the meaning of upholding a sense of normality within the context of a preterm birth. One first-time mother who experienced immediate SSC with her newborn after vaginal birth noted the following:Because he was inside of me and then on me, the whole time . . . also, it went so fast . . . you feel when they come out of you and you are like, “Did he fall on the floor, where did he go?” . . . but then that split second until I got him on my chest was like “Okay, but now everything is as usual again.”
      Participants described how SSC was meaningful in terms of giving them their parenting roles. Feelings of helplessness and of being an observer on the outside in a greatly medicalized situation were replaced by meaningfulness when participants held their newborns in SSC. They expressed this as feelings of participation and inclusiveness and being significant in the care for their newborns from the start. These feelings were stated by a second-time father after his partner had a cesarean birth:At first you just stood there watching . . . but then when you got her on you (skin to skin), then it felt like you were there because you were needed because then you could do something. . . . Otherwise you had no idea, you just sat there and waited for what would happen . . . but it felt good when I got her on me.

       A Calming Physical Sensation

      As part of this second subtheme, an important cascade of embodied knowledge started within the participants by the direct physical sensations of feeling and seeing their neonates during SSC. It became a tool for regaining control in an otherwise powerless situation, and parents were able to form their own opinions based on their direct experiences with their newborns. Participants could feel their newborns responding by becoming calm and relaxed. This in turn strengthened their sense of making a difference for their newborns and being able to interpret and respond to their newborns’ needs. A first-time father explained receiving his newborn for SSC:He cried when he was born, as soon as I had him on my chest, he became completely silent . . . something happens . . . I think he recognizes my voice, he recognized heartbeat, warmth, I made him calm, just by laying him on my chest.
      For one mother, SSC directly after birth supported a continuum in her relationship with her newborn, from recognizing her newborn’s behavior in the womb and now on her chest. In the same way that SSC was perceived as beneficial for the neonates, participants experienced that it was beneficial for them and created a perceived need in the parent and the newborn to be close and in early interaction. A first-time father described this benefit: “It feels like it makes her calm, and that makes me feel calm and secure . . . so the feeling was that we made each other feel secure and calm, that’s how it felt at least.”
      Being unprepared for preterm birth, some participants described SSC as an important starting point for realizing that they had become parents. The knowledge that came from physical sensations when in SSC created reciprocity and connectedness between the parent and the neonate. A father of twins noted the following upon receiving his firstborn immediately in the birth room:It was the first I saw, it was the first I got on my body . . . his whole body, when he relaxed on my chest . . . then it became a completely different situation and a completely different feeling in my body, then I thought, “Okay, this is my son.”

       Building Confidence Over Time

      To become a parent of a preterm neonate was described as a different start of parenthood. Participants indicated that a sense of normality was put on hold and replaced by a process of making sense of the neonate and themselves while parenthood evolved. Skin-to-skin contact provided an early seed of connectedness with the newborn, and its significance was sometimes understood first when reflecting back. Participants described the fruit of this seed and, thus, its possible impact over time as a sense of confidence in themselves as parents. At this point, they began a trust in their own abilities to know what was best for their newborns. Regardless of the situation, the participants all ascribed an important meaning to SSC afterward, as depicted by a first-time mother:But I feel the skin-to-skin contact has . . . I don’t question myself as I thought I would do as a mother . . . and the whole thing with like, “Oh, should I feel like this” or “Should it be like this,” it’s like “No, but it is us, I know.”

       Theme 2: Just Being in a Vulnerable State

      This theme was related to the act of being present in SSC as juxtaposed to the task of being present in SSC and how the experience of that presence was impaired by the various challenges participants faced around birth and how the health care staff met those challenges. The following three subthemes provided distinct features of this main theme: Physical and Mental Readiness, Presence: Easy and Hard, and A Person With Own Needs.

       Physical and Mental Readiness

      In this subtheme, participants described aspects of giving birth to a very preterm neonate that impaired their readiness for having their newborns in SSC. This did not necessarily mean that they wanted it another way but, rather, related to how the first time in SSC differed from the other times that followed. One aspect was meeting their newborns for the first time and how unprepared they were for what they saw. Seeing the neonate so small and fragile was frightening. The participants expressed feeling insecure in how to hold their newborns and scared that something would go wrong during SSC. This could lead them to want to withdraw and let staff take over. They described how the staff became an important catalyst for SSC before they felt more secure and prepared. After his partner had a cesarean birth, a first-time father stated the following:I don’t know . . . When you are there you first think that you want those who have the knowledge, fix everything . . . but I guess it’s good to participate. . . . I would absolutely do it again if I . . . to sit with her . . . I think it is good.
      Readiness for SSC could be impaired by the physical condition of the mother at the time of birth. When women experienced complications, SSC could be imposing. They first needed to ensure their own physical well-being before focusing on their newborns, and this tension created feelings of stress during SSC. Seeing her partner and newborn together in SSC could allow the mother to temporarily “let go” and feel some relief in that moment. One mother who gave birth vaginally to twins described her experience in immediate SSC with her second-born twin:I was in pain, and it became hard . . . and then I felt stressed that he was lying here (skin-to-skin), and that I could not have the right control over him . . . so I think, had it not been so problematic to get the placenta out it would have felt even better than it did right then . . . because I could not focus on him.

       Presence: Easy and Hard

      Participants described the task of being present with their newborns in SSC (as a task given to them) in comparison to the act of presence in SSC (as an inner state). They perceived the task of having their newborns in SSC as rather effortless, and the perceived simplicity of the task could be seen within the complexity of the birth of a very preterm neonate. A first-time father said, “‘I can’t do anything about this. I will just have to stand by the side and watch’ compared to ‘Well, now I have her with me. I am doing something, but still not.’”
      Although being present for their newborns was perceived as an effortless task, albeit an important one, being present with their newborns was more challenging in many instances. The act of being present in SSC was concerned with the quality of that presence, an inner state of being able to be “here and now.” For several participants, the first hours after birth were experienced as a haze; time and space somewhat merged, which pulled them away from fully being present in the moment with their newborns. Thoughts and worries about the future and everything that should be dealt with often led their minds elsewhere. Adapting to the physical environment in the NICU, including all the medical equipment surrounding the neonate, could also initially take the upper hand, as expressed by a second-time father: “You just disappear into a jumble of sounds and people and so on. . . . It was all as in a haze. . . . I probably had a hard time being present.”

       A Person With Own Needs

      With preterm birth, the focus of staff and parents was naturally on the newborn’s needs during the first hours after birth. In this subtheme, participants described how they put their own well-being aside in relation to their newborns. They often downplayed or suppressed their own needs in the moment or found it hard to express what those needs might have been. Given the shared focus on the neonate’s needs, there was a risk that the participants could be seen as tools for giving SSC rather than people with their own feelings and needs. One father described the following:Because I was sitting there with this baby and I just like . . . okay, there is staff, there is care, it will beep (from the monitor) if she is feeling bad . . . then I will just sit here then, like some kind of statue, a living statue that is not supposed to do anything but to just be there . . . and the purpose then?
      It was difficult for the participants to express their needs when they did not know what to expect. As a minimum requirement, they needed help with basic needs such as sitting comfortably in bed or in an armchair and having an opportunity to eat and drink when in SSC. Participants reflected on the need to optimize the organization between the maternity and neonatal units so they could stay together in SSC with their newborns. The maternity staff needed to be flexible to provide early postpartum care to the mother in the neonatal unit, and the neonatal unit needed to be prepared to facilitate care with supplies, medicine, etc. When this coordination was lacking, the women described their early postpartum care as suboptimal.

       Theme 3: Creating a Safe Haven in an Unknown Terrain

      This theme represented the relationship that was formed between the staff and the participants, what it was based on, and how it could provide a safe base for participants to be together with their neonates in SSC. The following two subthemes incorporate distinct aspects of this theme: Staff Behavior Is Key and Providing a Sense of Availability.

       Staff Behavior Is Key

      Preterm birth was more or less unexpected for the participants, and they shared feelings of not being fully prepared for what was to come and loss of control. From one moment to another, they moved into a new reality that they struggled to understand and adhere to. The staff members were the experts. To adapt to the unfamiliar, participants seemed to navigate toward forming relationships with the staff based on trust; in a sense, they had no choice but to choose trust. In addition, the staff tried to instill trust in the participants regarding their abilities to perform SSC. A first-time mother described the following after a cesarean birth: “They kept an eye on him all the time . . . but still, it felt like they were trying to encourage me to also see for myself how my child was doing.”
      Within this relationship, participants constantly “read” the staff and interpreted good and bad signs based on staff behavior. The staff’s ability to be calm and provide a sense of confidence in what they were doing made the participants calm and gave them a feeling of security. Staff were described as supportive when they prepared participants in any way possible for the next step. Continuous preparations and affirmation from staff helped the participants gradually feel more in control over themselves and the situation. A father of twins stated,You were told beforehand that they were going to get this in their nose so they could breathe . . . so you got information the whole time, so it was not just that I got them on my chest and that it came as a shock for me that they were putting in things in his nose and stuff. . . . When you got information you became calm.

       Providing a Sense of Availability

      If holding a very preterm infant in SSC at birth was an act based on trust between the parent and the staff, its leverage was a continuous movement between giving participants enough space for being together with their newborns in a meaningful way while providing them with a sense of staff availability to feel secure within that given space. A first-time mother noted the following after a cesarean birth:So that when you get him on your chest you can feel that they don’t leave you. . . . They might have gone away a bit, but then they peek in their heads and like, “How is it going?” So you still feel like you have a little . . . that you are doing something yourself, too.
      The physical space was adapted to support calm and rest during SSC by using screens around the dyad. However, for some participants, there was a fine line between the restorative state created within a partitioned physical space and the physical space per se, which created a feeling of isolation. During SSC, participants were dependent on the availability of the staff to feel secure. The staff seemed to monitor this need individually by checking in and showing they were available. However, some participants felt that their ability to communicate with the staff when in SSC was limited and insufficient. To address this problem, several participants suggested the use of a buzzer to get the staff’s attention.

      Discussion

      Our findings provide novel insight of a period when most very preterm neonates are cared for while separated from their parents until stable enough for SSC. To our knowledge, this is the first study to explore parents’ experiences of SSC after the birth of a very preterm neonate and during the first hours when the neonate is undergoing physiologic stabilization.

       Parent–infant connectedness

      Our findings underscore that SSC at birth is an important intervention to reinforce the early process of becoming a parent for healthy full-term (
      • Dalbye R.
      • Calais E.
      • Berg M.
      Mothers’ experiences of skin-to-skin care of healthy full-term newborns—A phenomenology study.
      ), moderately preterm (
      • Dahlø R.H.
      • Gulla K.
      • Saga S.
      • Kristoffersen L.
      • Eilertsen M.-E.B.
      Sacred hours: Mothers’ experiences of skin-to-skin contact with their infants immediately after preterm birth.
      ), and very preterm neonates, as shown in this study. After the birth of a preterm neonate, parenthood is often described as a delayed process with an alteration in the parenting role. The initial separation, often attributed to the neonate’s medical condition and need for technological support, can lead parents to feel disconnected from their newborns (
      • Spinelli M.
      • Frigerio A.
      • Montali L.
      • Fasolo M.
      • Spada M.S.
      • Mangili G.
      ‘I still have difficulties feeling like a mother’: The transition to motherhood of preterm infants mothers.
      ) and less confident in their parenting roles (
      • Sisson H.
      • Jones C.
      • Williams R.
      • Lachanudis L.
      Metaethnographic synthesis of fathers’ experiences of the neonatal intensive care unit environment during hospitalization of their premature infants.
      ;
      • Spinelli M.
      • Frigerio A.
      • Montali L.
      • Fasolo M.
      • Spada M.S.
      • Mangili G.
      ‘I still have difficulties feeling like a mother’: The transition to motherhood of preterm infants mothers.
      ). Our findings suggest that when SSC is seen as the primary place of care directly after a very preterm birth, parents can be actively engaged in a meaningful way in their parenting roles from the very start alongside the necessary medical treatment for their newborns, which is a new insight.
      Central to their experiences, the participants described an early connectedness with their newborns, which was mediated through the calming physical sensations during SSC. This gave them access to an embodied knowledge of their newborns even when born very preterm.
      • Flacking R.
      • Thomson G.
      • Axelin A.
      Pathways to emotional closeness in neonatal units – A cross-national qualitative study.
      similarly described this in the theme Embodied Recognition Through the Power of Physical Closeness as a pathway to parent–infant emotional closeness after a preterm birth. At a physiologic level, these descriptions reflect the neuroendocrine mechanisms involved in positive social interactions and bonding. Here, close physical contact, such as SSC, is the stimulus that exerts the release of the hormone and neurotransmitter oxytocin, which is known to enhance the sensitivity of the parent and the newborn to each other (
      • Moberg K.U.
      • Handlin L.
      • Petersson M.
      Neuroendocrine mechanisms involved in the physiological effects caused by skin-to-skin contact—With a particular focus on the oxytocinergic system.
      ). Maternal and paternal oxytocin levels have been found to significantly increase during SSC with a preterm neonate (
      • Cong X.
      • Ludington-Hoe S.M.
      • Hussain N.
      • Cusson R.M.
      • Walsh S.
      • Vazquez V.
      • Vittner D.
      Parental oxytocin responses during skin-to-skin contact in pre-term infants.
      ), and a positive relationship has been shown between oxytocin release during SSC early in the NICU stay and parent engagement at NICU discharge (
      • Vittner D.
      • Butler S.
      • Smith K.
      • Makris N.
      • Brownell E.
      • Samra H.
      • McGrath J.
      Parent engagement correlates with parent and preterm infant oxytocin release during skin-to-skin contact.
      ). This suggests that experiences with SSC during the early postpartum period affect parent behavior later on. In our study, the experience of early connectedness was also described as having an effect over time. Participants expressed a sense of confidence in themselves as parents, even after very preterm birth. This sheds light on the organization and care routines for parents with preterm neonates admitted to the NICU, including very preterm neonates, in the period immediately after birth. Most maternity and neonatal units have yet to successfully manage to combine a woman’s postpartum care with the neonate’s care in the NICU (
      • Klemming S.
      • Lilliesköld S.
      • Westrup B.
      Mother-Newborn Couplet Care from theory to practice to ensure zero separation for all newborns.
      ).
      Parents of very preterm neonates need to be provided care during the immediate postpartum period that is coupled with the care for their newborns.

       Parent vulnerability

      Although immediate SSC was described as an empowering experience, participants spoke of themselves from a position of vulnerability at a time that imposed challenges. This sense of vulnerability stemmed from the unfamiliar situation and environment, which placed them in subordinate and dependent positions to the staff. This also related to their inner states and emotions after very preterm birth. At this time, the women were patients themselves, with individual birthing experiences and medical needs. Our findings suggest that to support parents in this situation, they should be understood and addressed from this position of vulnerability. Parents’ mental readiness for SSC has been highlighted in previous research, in which a fragile or unstable neonate can evoke conflicting emotions and needs and lead the parent to want to withdraw (
      • Maastrup R.
      • Weis J.
      • Engsig A.B.
      • Johannsen K.L.
      • Zoffmann V.
      ‘Now she has become my daughter’: Parents’ early experiences of skin-to-skin contact with extremely preterm infants.
      ;
      • Skene C.
      • Franck L.
      • Curtis P.
      • Gerrish K.
      Parental involvement in neonatal comfort care.
      ). As in our study, staff encouragement to initiate SSC has previously been identified as important for parents to overcome initial fears and uncertainties (
      • Kymre I.G.
      • Bondas T.
      Balancing preterm infants’ developmental needs with parents’ readiness for skin-to-skin care: A phenomenological study.
      ;
      • Maastrup R.
      • Weis J.
      • Engsig A.B.
      • Johannsen K.L.
      • Zoffmann V.
      ‘Now she has become my daughter’: Parents’ early experiences of skin-to-skin contact with extremely preterm infants.
      ). An interesting finding in our study was that of a need of physical readiness for SSC, which was especially vivid for one woman experiencing medical complications at the time of birth. On the contrary, another woman tolerated receiving her very preterm neonate directly skin to skin in the birth room very well. This calls on great sensitivity from the staff regarding the timing and initiation of SCC and in engaging the partner if needed until the woman feels physically more grounded in the recognition of SSC as being an interactive process.

       Providing a safe base

      Our findings have an interesting paradox between the mere simplicity of being present in SSC and the more challenging act of being present when in SSC in the early hours after birth. The ability of the staff to shift the focus from SSC as a task to be performed to an interactive process between the parent and the neonate might be an important key in their ability to support parents. A key issue for being present during SSC was feeling secure. Feeling a sense of security is most likely of importance to parents to enable them to stay in the presence of and interact with their very preterm newborns. The participants’ senses of security were mediated through the relationships formed with the staff, which were appreciated when providing them with a sense of availability while giving them space to be with their newborns. Similarly,
      • Treherne S.C.
      • Feeley N.
      • Charbonneau L.
      • Axelin A.
      Parents’ perspectives of closeness and separation with their preterm infants in the NICU.
      recognized a need for parents to feel that they are spending time alone with their newborns in the NICU while, at the same time, depending on staff availability for support; they described the staff behavior as “acting as a supportive shadow.” Autonomy has been described as a key element in parents’ perceptions of closeness to their preterm neonates (
      • Treherne S.C.
      • Feeley N.
      • Charbonneau L.
      • Axelin A.
      Parents’ perspectives of closeness and separation with their preterm infants in the NICU.
      ). In our study, participants’ moves toward autonomy were already present during SSC, given that staff managed to make them feel secure. Our findings emphasize the need for health care staff to fully understand and embrace their unique role as the enabling force for initiating SSC at the practical and emotional levels.

       Limitations

      In the present study, all the participants were native Swedish speakers, and the transferability to other cultural contexts should therefore be taken into consideration. However, a purposive sampling was used to enhance variation within the group of parents who were interviewed. Another potential limitation was that the participants were part of an intervention group in a randomized controlled trial. This might have created a different approach from the staff. Nevertheless, clinical and caring routines were the same for these families as for others during SSC later on in the NICU and with the same staff providing the care. Furthermore, all participants were familiar with the researcher who conducted the interviews because they had met during the implementation of other parts of the IPISTOSS. A risk might be that the participants felt a need to answer according to perceived expectations from the involved researcher. However, on the contrary, the experience was that a relationship between the parents and the researcher had already been formed, which facilitated an open and reflective atmosphere during the interviews. Indeed, a strength of the study was the quality of the interview in terms of richness, depth, and nuance. Another strength was the representation of women’s and men’s perspectives.

      Conclusion

      We found the intervention of immediate SSC at birth for very preterm neonates to be a valuable and empowering experience for parents that enhanced early connectedness and bonding. Parents of very preterm neonates should be understood and treated while acknowledging their vulnerable position, and SSC should be recognized by staff as an interactive process. Support is achieved by forming a relationship with staff that provides parents with a safe base to be with their newborns, mediated through staff behaviors and availability. Women who have just given birth need to be provided postpartum care coupled with care for their very preterm neonates. Our findings can be used in education to enhance staff awareness for parental needs within maternal and neonatal settings when SSC is being implemented for very preterm neonates at birth and to emphasize the need for adequately designed and staffed maternal–neonatal couplet care units. To further promote immediate SSC at birth for very preterm neonates as a routine health care practice, future research is also warranted to understand the needs of nursing staff who provide the initial postnatal care.

      Conflict of Interest

      The authors report no conflicts of interest or relevant financial relationships.

      Funding

      Funded by the Doctoral School in Health Care Sciences and Strategic Research Area Health Care Science at Karolinska Institutet, Swedish Research Council, Region Stockholm, Kempe Carlgrenska Fonden, and Sällskapet Barnavård.

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      Biography

      Siri Lilliesköld, RN, MSc, is a specialist nurse, Neonatal Intensive Care Unit, Karolinska University Hospital, Stockholm, Sweden, and a PhD candidate, Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden.
      Sofia Zwedberg, RN, RM, PhD, is an associate professor in the Department for Health Promotion Science, Sophiahemmet University, Stockholm, Sweden, and a midwife, Pregnancy Care and Delivery Unit, Karolinska University Hospital, Stockholm, Sweden.
      Agnes Linnér, MD, is a neonatologist, Neonatal Intensive Care Unit, Karolinska University Hospital, Stockholm, Sweden, and a PhD candidate, Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden.
      Wibke Jonas, RM, PhD, is an assistant professor, Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden.