Booby Traps Series: Staff motivation can get in the way of Kangaroo Care and Skin-to-Skin

This post is the 23rd in a series on Booby Traps made possible by the generous support of Motherlove Herbal Company.

To borrow a phrase, if there were a drug that could do the following things for premature and/or term infants, would it be ethical not to use it?

  • Better survival rates in preterm babies
  • Better oxygenation
  • Better heart rate*
  • Better temperature
  • Opportunity to self attach to the breast
  • Lower stress hormones
  • Less crying
  • Better blood sugars
  • Better immunity, even six months later
  • Lowered risk of infection
  • Lowered risk of necrotizing enterocolitis
  • Increased maternal attachment
  • Increased breast milk supply
  • Increased maternal confidence in ability to care for babies
  • Increased maternal confidence that their babies are well cared for
  • Increased maternal sense of control
  • Better rates of breastfeeding, even many months later**

The ‘drug’ is your skin, in contact with your baby’s skin.  All of these things occur when your baby is held in skin-to-skin contact with you. 

Research has even shown that our chest temperature automatically increases right after birth – a built in “warmer” for our babies.  And since I have your attention, I’m going to take this opportunity to share my favorite trivia about skin-to-skin:

1) If you graph a baby’s temperature in an incubator, which uses a sensor to gauge a baby’s temperature and raise or lower the warmth, the graph will show the baby’s temperature in a wave-like pattern because there is a delay as the incubator responds to the baby’s temperature.  Compare that to a baby on its mom’s chest.  What does the graph look like?  A straight line.  The mother’s chest raises and lowers the temperature instantaneously.  Beat that, machine.

2)  If you place twins on their mother’s chest, one on each breast, each breast will raise and lower its temperature independently to meet the warmth need of each baby.

Though it’s logical to assume that this has been practiced for ages by mothers, research demonstrating the benefits of keeping babies in their natural habitat (mothers’ bodies) dates to 1979, when two doctors in Bogota, Columbia stumbled upon a dramatic finding.

Drs. Rey and Martinez were trying to care for preterm infants in an extremely resource-poor environment.  There was a shortage of warmers.  The mortality rate of premature infants there was about 70%.  Then, they began recommending that mothers hold their babies, skin-to-skin between their breasts as much as possible, and breastfeed on cue.

A miraculous thing happened:  the mortality rate of their patients wasn’t 70%.  It was 30%.

This practice became known as Kangaroo Care, and subsequent research in many other developing countries confirmed their findings.

The next question that needed to be answered was whether there was any benefit to full term babies.  And the answer, established by this review of 18 studies, is a resounding yes.  The World Health Organization fully supports it for all babies, declaring: “Almost two decades of implementation and research have made it clear that KMC is more than an alternative to incubator care. It has been shown to be effective for thermal control, breastfeeding and bonding in all newborn infants, irrespective of setting, weight, gestational age, and clinical conditions.”

So, are hospitals fully supportive and encouraging of Kangaroo Care and skin-to-skin?  I think that it’s safe to say that things are moving in that direction, but there is a lot of work yet to be done.

The most obvious place to look for progress is in the nation’s NICUs, since evidence for Kangaroo Care has been around the longest for preterm babies.  A national survey in 2002 found that 82% of NICUs were practice kangaroo care, and I would imagine that that number has increased in the ten years since.  But barriers exist, even there, and one of the key reasons is staff education and motivation.

The survey found that the practice of Kangaroo Care was more strongly influenced by perceptions than evidence.  As summarized in this article, it found that “Staff reluctance seemed particularly focused on the misconception that kangaroo care would require extra work on their part.” Another study published in 2011 which looked into barriers to kangaroo care found, “Key institutional factors were education and motivation of staff.”

While I couldn’t find any national data on the use of skin-to-skin in full term babies, I can say that I’ve heard similar objections to routine skin-to-skin care.  There is a perception that encouraging moms to hold their babies skin-to-skin will create more work for hospital staff, when in fact the opposite appears to be true.  Babies held skin-to-skin cry less, feed better, and need less care generally because they are in a much more stable state.  Moms are happier, too, and isn’t it possible that this results in fewer call buttons being pushed?

Culture change is hard, and takes time, but the evidence in favor of Kangaroo Care and skin-to-skin makes encouragement of these practices an imperative.

Did your hospital encourage skin-to-skin (or kangaroo care, if you had a preemie)?

* As with breastfeeding, we could discuss these outcomes in terms of the risks of not holding a baby skin-to-skin, rather than “better” rates associated with holding a baby skin-to-skin.  For example, we could say “When a baby is separated from its mother, its heart rate slows to an abnormally low rate as part of a “protest- despair” response.   A return to skin-to-skin contact with the mother restores a normal heart rate.”  Another example:  “A baby removed from its mother is at higher risk for hypothermia than a baby in its normal state – held skin-to-skin with its mother.”

** Skin-to-skin is great for all babies, whether breastfeeding or not.

13 thoughts on “Booby Traps Series: Staff motivation can get in the way of Kangaroo Care and Skin-to-Skin

  1. The nurses at the hospital where I delivered strongly encouraged skin to skin contact. When they were teaching me how to fed my daughter in the hospital, they started by telling me take her shirt off and hold her against my bare chest. She was a late term preemie. (36.5 weeks) Of course, this is at a hospital with the Baby Friendly certification, so I suspect that might be part of the difference.


  2. Do you have any research on skin to skin vs warmers in the or after a csection? I would LOVE to have this, but my ob says no… research might help change her mind… (20 weeks along now, so only 17 or 18 left to come up with something. And without research to back me up, husband will side with dr. With research, he’s on my side! )


      1. Thanks Tanya!
        I’ll pass this along … I really want to do skin to skin for this one – didn’t know about it for my first.

        I’m also picking my battles – didn’t say anything about repeated unnecessary blood tests, etc. But hit ’em with research and insisted on continuing to nurse my (then) 17 mo old when they recommended weaning her ’cause I was pregnant. (Won that round… and hopefully made it easier for the next momma! )


  3. My daughter was born at 34 weeks in 2005. I would say that skin-to-skin was NOT encouraged. In the first place, although her Apgar scores were 8 and 8 (good for a full-term infant), she was removed from me within a few minutes of birth and taken to the NICU. Immediately, our bonding was interrupted. She spent a week in the NICU, which was a large, open, bright room with dozens of other babies in their own isolettes. The only seating were uncomfortable chairs that had you sitting straight upright, and I wasn’t able to do that for long periods because I had severely hemorrhaged following the birth. While they did provide rolling screens, it was far from what I would call a relaxing and intimate environment, where I would be comfortable hanging out topless and bonding with my newborn. Dimmer lighting and more privacy would have gone a long way to changing that, as well as staff support, which was sort of mixed.

    When my son was born at 39 weeks, in contrast, he was handed directly to me and we got to spend his first hours skin-to-skin. I feel really sad that my preterm baby, who arguably was more in need of kangaroo care, didn’t receive it in the same way as my full-term baby.


    1. Amber, that is so sad. I do hope that hospital, and all others with similar policies and and conditions, make positive changes in the very near future.


  4. Nope. They took her to the nicu for a few hours gave her formula, and brought he rback to me at 1 in the morning wrapped in a blanket and told me I couldnt’ feed her til 4 am when they did bloodwork. :(. The next morning the LC came in with abottle of formula and told me I needed to supplement. Needless to say BFing didn’t get off to a great start, but we persevered adn are still going strong at 15 months


    1. I’m sorry the staff threw those booby traps in your path but I’m so inspired by moms like you who beat ’em.
      Isn’t nursing a toddler fun and crazy? 🙂


  5. My twins were born at 33 weeks, went immediately to NICU. I understood though, it was necessary. 12 hours later when I was allowed to leave my room I went to visit them. We had a great NICU, dim lighting, very quiet, large reclining chairs with foot rests, and privacy screens. The NICU doctor encouraged skin-to-skin time but I wish the NICU nurses would have initiated it or helped me with it. I basically had to decide on my own to do it, get my shirt off, undress my baby, set up the screen, get laid back in the chair… All of it myself. Well, my husband helped too. There is a lot of room for improvement with this, the nurses need to initiate it, encourage it, and help with it instead of just sitting aside, letting the mom (recovering from a C-section, with TWO babies in NICU!) do everything herself.


  6. Kangaroo Care is a miracle drug in my opinion. I had a 29week micropreemie. It was several days before we go to hold him but by the end of the first week we had held him. I could go into the NICU and watch the monitors go up and down and watch the oxygen levels drop enough to continually set off the alarms. Then we would start Kangaroo Care. Numbers would stabilize, oxygen levels would increase to near 100%. Happened this way every time. It was the best thing for him. And 95% of the nurses were very encouraging of it and actually helped with it–helped get the baby uncovered quickly and all the wires assembled, etc.


  7. During my delivery, I was transferred from the midwife clinic to the main regional hospital (meconium in water). I was nervous that the hospital would try to force me into a medicalized birth. I was also nervous that my midwife would have to fight with the staff to get things done her way. Not so. In fact, there were about 10 hospital staff present for the birth of my son, but the midwife just got on with it. Mine was the first fully non-medicalized birth some of the staff had ever witnessed. They put him on my chest, I immediately started breastfeeding. I did unwrap him before I started breastfeeding, and one nurse started to tell me to stop, but when I said, “I got this, thanks” she just stepped back and let me carry on. Oh, and even though it was a hospital setting, the midwife got them to release me less than 12 hours later. Hospital staff at Alaska Regional were very supportive of skin to skin, breastfeeding, and all those natural things I wanted out of my birth. I went in there expecting a struggle, and I walked out feeling pleasantly surprised.


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