Does immediate parent-infant skin-to-skin contact improve interaction in very preterm babies at 4 months?

In a recent study published in JAMA Network Open, researchers investigated the effect of initial skin-to-skin contact (SSC) at delivery on the quality of mother-infant interactions at four months of corrected age in extremely preterm infants.

​​​​​​​Study: Skin-to-Skin Contact at Birth for Very Preterm Infants and Mother-Infant Interaction Quality at 4 Months. Image Credit: Irina Bg/


SSC is a conventional technique of care for preterm newborns, particularly those at risk of immaturity. The World Health Organization (WHO) indicates SSC immediately postnatally due to increased survival rates.

However, research on the long-term developmental implications of SSC in very preterm newborns is scarce. High-quality interactions between the parent and their infant safeguard the infant's socioemotional, behavioral, and cognitive development.

SSC can promote mother-preterm newborn interaction patterns; however, there has been limited research on its effects when commenced shortly after delivery.

About the study

In the present study, researchers investigated whether SSC between parents and their very preterm children immediately post-delivery was more effective than regular incubator care in enhancing mother-infant interactions at four months. They secondarily analyzed the Immediate Parent-Infant Skin-to-Skin Study (IPISTOSS) data.

The IPISTOSS randomized controlled trial (RCT) was conducted between April 1, 2018, and June 30, 2021, at three neonatal care units in Norway and Sweden. Very preterm neonates (gestation week 28 to week 33) and their mothers and fathers were followed for four months until December 2021.

The data were analyzed on 16 March and 18 September 2023. The team excluded infants with congenital malformations, infections, or contraindications to participate in the study.

Infants were randomized to receive regular incubator care (control group, n=37) or skin-to-skin contact with one of the parents (intervention group, n=34) beginning at delivery and continued through six hours post-birth.

The study outcome was the quality of mother-infant interactions, assessed using the Parent-Child Early Relational Assessment (PCERA) scores and five-minute mother-infant free-play video recordings at four months of age.

Two dyadic scales were combined into a single scale, producing five subscales: (i) maternal positive affect, responsiveness, and sensitivity; (ii) maternal negative affect and behavior; (iii) infant positive affect, social, and communicative skills; (iv) infant irritability and dysregulation; and (v) dyadic emotional tone, regulation, and reciprocity. Multilevel regressions were performed to estimate the effects of the dichotomous SSC vs. control variable on PCERA subscales and total skin contact time.

The team screened women with threatening preterm labor in obstetric units and obtained data on maternal psychiatric well-being status (Spielberger State-Trait Anxiety Inventory and Edinburgh Postnatal Depression Scale) and stress levels among parents (Swedish Parenthood Stress Questionnaire).

After a vaginal birth, SSC was initiated with the mother, while after cesarean section delivery, it was on the father’s chest until the mother could be transferred to the neonatal intensive care unit. Twins were cared for with one parent or together with either parent.

The team recorded SSC duration using the Parent-Infant Closeness Diary. Two certified coders, blinded to the intervention, rated data and agreed on 82% of items on a categorical level.


In total, 56 mothers and 71 infants (31 twins) were analyzed. The mean values for infant gestational age and birthweight were 31.3 weeks and 1,535 g, respectively; 59% (n=42) were male, and 41% (n=29) were female. The mean maternal age was 32, and 57% (n=32) were primiparous. SSC was initiated 15 minutes post-birth (median).

At follow-up, 22% (n=20) of randomized infants withdrew from the study; however, no differences were found between analyzed infants and dropouts, minimizing attrition bias risk in the study. Fathers showed higher SSC durations during the six hours post-birth than mothers, with median values of 3.3 hours and 0.8 hours, respectively.

The team observed significant differences in the third PCERA subscale (neonatal positive affect, social, and communicative skills), with maternal-neonatal interactions of higher quality in the skin-to-skin contact group at four months. This effect was significant post-adjustment for child sex, primiparity, and observational settings (clinic versus home).

Post-intervention, the total SSC duration for infants was higher in the SSC group during the initial 72 hours, with median values of 17 hours vs. 10 hours among controls. This group’s total SSC duration was also higher in the initial eight days, with median values of 52 hours vs. 37 hours.

No statistically significant effects were observed in the mediation analyses performed to investigate whether the impact of SSC versus the control on the third PCERA subscale was mediated by the total SSC duration at 72 hours and eight days post-birth.


Overall, the study findings showed that SSC could enhance the mother-infant bond, and healthcare procedures should encourage it after birth. There is an early sensitive time after delivery for extremely preterm infants, with good affect, social, and communicative abilities most favorable in mother-infant dyads assigned to immediate SSC.

After adjusting for observation conditions, dyadic interaction was more ideal in the SSC group. The contributions of mothers to interaction quality were not different among groups.

Immediate SSC is notably good for the interactive activities of very preterm infants and may enhance the dyadic components of the relationship. The duration of SSC after delivery is crucial, and either of the parents may offer it to their infants.

Journal reference:
Pooja Toshniwal Paharia

Written by

Pooja Toshniwal Paharia

Dr. based clinical-radiological diagnosis and management of oral lesions and conditions and associated maxillofacial disorders.


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