As parent advocates highlighting the obvious problems, inaccuracies and outright untruths in infant feeding policy, we often feel like the little boy in the crowd pointing out that the emperor has no clothes on. This is never more the case than when confronted with the idea of ‘skin-to-skin’.
Any parent who has had a baby in the last two decades has heard of ‘skin-to-skin’. To the layperson, it is a mother holding her baby naked to her naked chest after birth. But according to our healthcare authorities, who are following so-called ‘Baby Friendly’ guidelines from UNICEF, it is so much more than this and we all need to be prescribed it.
Everyone wants to meet and cuddle their baby after they are born. That includes dads and partners who didn’t give birth, and IFA is fully in favour of parents doing this however they feel comfortable. But according to the so-called Baby Friendly Initiative, not any cuddle is good enough and parents need educating. Because when a newly postnatal mother holds a baby naked for an hour under the guidance of a healthcare professional, something else happens; something magical; something animal:
‘When a mother holds her baby in skin-to-skin contact after birth, it initiates strong instinctive behaviours in both. The mother will experience a surge of maternal hormones and begin to smell, stroke and engage with her baby. Babies’ instincts after birth will drive them to follow a unique process, which if left uninterrupted will result in them having a first breastfeed.’ (Baby Friendly UK website.)
Woe betide those women whose instincts tell them they are not physically stable enough to hold their precious, fragile baby for very long, or those who dare suggest they have their own ideas for how they want to meet their baby, or even that their partner does the cuddling. Pity those who miss out on this ‘crucial’ event because of their own urgent medical needs or those of their baby.
For Baby Friendly UK, skin-to-skin is the first part of an origin story about motherhood, bonding, love, relationships and breastfeeding. When mothers have skin-to-skin contact during what is fantastically named the ‘golden hour’, they will almost certainly be able to breastfeed and will bond better with their babies and all of this leads to better outcomes for the rest of the child’s life, and on top of this, skin-to-skin has loads of other short-term benefits to the baby adjusting to the world too.
But just like the emperor wearing marvellous new clothes, this outlandish story about skin-to-skin is a fantasy. The most recent Cochrane review of the evidence for skin-to-skin found no good evidence that skin-to-skin improves any health outcomes for healthy term babies. It concluded: ‘methodological quality of trials remains problematic, and small trials reporting different outcomes with different scales and limited data limit our confidence in the benefits of SSC [skin-to-skin contact] for infants.’
It found some low and moderate quality evidence for an association between skin-to-skin and the longer duration of breastfeeding during the first four months. However, it found ‘inadequate evidence with respect to details of SSC [skin-to-skin contact] such as timing of initiation and dose’. Ultimately, it recommended ‘skin-to-skin’ on the basis of these underwhelming findings and because there was no evidence of harm.
Unfortunately, there is now evidence of harm. In 2020, the Healthcare Special Investigations Branch (HSIB) published an investigation into a small number of deaths of babies that took place during skin-to-skin contact, categorised as deaths by sudden unexpected postnatal collapse (SUPC).
When the report titled ‘Neonatal collapse alongside skin-to-skin contact’ came out, we thought that finally there might be some perspective on the subject of skin-to-skin, and that the tragic deaths of at least six babies in which skin-to-skin was implicated would lead to scrutiny of this over-hyped intervention with limited evidence to recommend it.
So, we were horrified to open the report and find on the first page, a foreword by the director of Baby Friendly UK, the organisation most invested in the promotion of skin-to-skin (Baby Friendly introduced the idea of skin-to-skin to the UK in its guidelines for ‘promoting, protecting and supporting breastfeeding’).
As we read on, our hearts sank. Not only had HSIB collaborated with a key stakeholder in what was supposed to be an independent investigation, but, quoting from Baby Friendly UK’s website and other resources, it repeated mistruths and misleading statements about skin-to-skin and what the evidence shows. It said:
‘A Cochrane systematic review has shown through randomised controlled trials that skin-to-skin contact in the first hour after birth:
• calms and relaxes both mother and baby
• regulates the baby’s heart rate and breathing, helping them to better adapt to life outside the womb
• stimulates digestion and an interest in feeding
• regulates the baby’s temperature
• enables colonisation of the baby’s skin with the mother’s friendly bacteria, thus providing protection against infection
• stimulates the release of hormones to support breastfeeding and mothering.’
But the Cochrane review showed nothing of the sort. It did not find evidence from randomised trials to confirm any of these benefits. It discussed a range of such claims, theories and hypothetical benefits in its background section. In fact, the results from the systematic review of randomised trials were inconclusive, as explained above, leading the authors to have ‘limited confidence’ in the benefits of skin-to-skin for babies.
So, IFA wrote to HSIB in 2021. We asked them why Baby Friendly UK had collaborated on the investigation, despite the breathtaking conflict of interest. We questioned how the report could be deemed independent in light of Baby Friendly’s involvement. And we pointed out the problems with their presentation of the evidence from the Cochrane review (you can read our letter in full here).
HSIB replied and graciously offered to meet us. We met them and had a lively discussion. They told us that their investigation had been met initially with accusations that they were trying to stop women from breastfeeding. They were proud to have managed to eventually engage Baby Friendly. We won’t repeat everything that was said in that meeting out of respect, but the outcome of the meeting was…not much.
We wrote once again to HSIB in 2021 to thank them for meeting us and to ask that, at the very least, they correct the misinformation about the Cochrane review in the report. We have still not had a response to that email, and the misleading information about the evidence base for skin-to-skin remains.
In the report, instead of making recommendations for practice, HSIB say they worked with Baby Friendly UK to update their guidance on skin-to-skin contact. These updates include: ‘Observation of the mother’s vital signs and level of consciousness should be continued throughout the period of skin-to-skin contact. Mothers may be very tired following birth and so may need constant support and supervision’ and ‘Many mothers can continue to hold their baby in skin-to-skin contact during perineal suturing, providing they have adequate pain relief.’
So, HSIB are concluding that women whose vital signs need monitoring and are at risk of unconsciousness, or women who are having a surgical procedure done should hold a newborn baby for an hour! And according to our conversation with them, a compromise with Baby Friendly to update their guidelines to say that skin-to-skin just needs some closer monitoring is a successful outcome of this investigation.
The impractical idea that skin-to-skin can be made safe through closer monitoring now seems to be having a wider impact. The British Association of Perinatal Medicine (BAPM) has recently incorporated this recommendation into its update to the ‘NEWTT’ clinical tool for early detection of deterioration in newborns. Unfortunately, BAPM also seems to have been captured by the cult of skin-to-skin, saying in the framework for this important clinical guideline:
‘Skin-to-skin contact is recommended for newborn infants within the first hour to promote thermoregulation, colonisation with maternal flora and biological nurturing’. (BAPM, 2023.)
But there remains no evidence that skin-to-skin improves any outcomes for term babies or that the outlandish claims made by Baby Friendly, HSIB and now BAPM are true. So, as the small boy in the crowd, IFA asks: Why are we mandating a practice that we know to have been implicated in the deaths of at least six babies, that has no evidence of significant benefit and that parents have not asked for, but trying to do it ‘as safely as possible’? Why are we prioritising the demands of UNICEF Baby Friendly above the evidence base, the safety concerns and the desires of parents?
It is time to stop appeasing Baby Friendly. It is time to ask how they have managed to get themselves written into the Long Term Plan for the NHS and now the NEWTT clinical early warning tool for identifying deterioration in newborns babies.
IFA is in favour of parents holding their babies, clothed or unclothed, washed or unwashed for as long as they feel comfortable and happy to do so after birth. This is a personal and private matter. But let common sense prevail when medical emergencies require a change of plan or parents, exhausted from birth want to put the baby down. And let no parent ever suffer a moment of anxiety that a lack of 60 minutes of naked cuddling after birth might have a detrimental effect on their bond with their baby or their baby’s health. This does not fit with any evidence or any respected theory of attachment. The promotion of this shaming and nonsensical idea is clearly not in the interests of women or their babies.
Let’s stop the wild exaggeration of benefits of skin-to-skin. Let’s stop pressurising parents in how they meet their baby and prescribing how they approach those first moments. Let’s stop encouraging women who have just given birth into practices that may not feel safe to them. Finally, let’s stop accommodating the demands of Baby Friendly UK and treading carefully around this powerful organisation. The evidence doesn’t support their claims…
Look! The emperor has no clothes on!