Immediate or early skin‐to‐skin contact for mothers and their healthy newborn infants

Abstract

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

Plain language summary

What is known about the benefits of immediate or early skin‐to‐skin contact for mothers and babies?

Key messages

• Mothers who have skin‐to‐skin contact with their babies in the first hour after birth are probably more likely to breastfeed exclusively up to one month later and from six weeks to six months later.

• Skin‐to‐skin contact between mothers and newborns probably helps newborns adapt to life outside the womb by keeping their body temperature stable and increasing their blood sugar levels. It may also help their breathing and heart rate.

• Skin‐to‐skin contact may result in little to no difference in the time until the delivery of the placenta. The effect on the mother's blood loss after a vaginal birth is unclear.

What is the issue?

Major global health groups like the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) advise that right after birth, a newborn should be placed directly on the mother's bare skin. The baby should be naked and stay there without interruption for at least an hour, ideally until after the first breastfeeding. This is called skin‐to‐skin contact. However, in many settings, it is common practice to separate newborn infants from their mothers, wrap or dress them, or place them in open cribs or under radiant warmers. Skin‐to‐skin contact is less common in low‐income countries and lower‐middle‐income countries. Because this practice can help mothers breastfeed successfully, lower rates of skin‐to‐skin contact may be one reason breastfeeding levels vary between nations with different income levels.

What did we want to find out?

We wanted to expand our understanding of how skin‐to‐skin contact at birth affects breastfeeding duration and exclusivity and the baby's transition to life outside the womb. Specifically, we wanted to know if skin‐to‐skin contact is better than standard contact for improving:

• exclusive breastfeeding;

• infant body temperature;

• infant blood sugar levels;

• infant breathing and heart rate;

• time to delivery of the placenta;

• maternal bleeding after vaginal birth.

What did we do?

We searched for randomized studies of immediate skin‐to‐skin contact (starting less than 10 minutes after birth) and early skin‐to‐skin contact (between 10 minutes and 24 hours after birth) in major databases. In randomized studies, participants are randomly put into two or more groups to ensure the groups are similar. We summarized the results and evaluated our confidence in their findings based on factors like study size and methods.

What did we find?

We found 69 studies with 7290 mother‐infant pairs. Most studies compared immediate skin‐to‐skin contact (within 10 minutes of birth) with standard hospital care for women with healthy full‐term babies. In 15 studies, women had a cesarean birth, and in 10 studies, the babies were healthy but born preterm (from 34 weeks but before 37 weeks of pregnancy). Thirty‐two studies were conducted in high‐income countries, 25 in upper‐middle‐income countries, and 12 in lower‐middle‐income countries, including India, Nepal, Pakistan, Vietnam, and Zambia. No studies were conducted in low‐income countries.

Main results

Women who have immediate skin‐to‐skin contact with their newborns are probably more likely to exclusively breastfeed at hospital discharge and up to one month after birth (12 studies, 1556 mother‐infant pairs) and from six weeks to six months after birth (11 studies, 1135 mother‐infant pairs).

Babies who have immediate skin‐to‐skin contact with their mothers probably have higher body temperatures 30 minutes to 2.5 hours after birth, although the difference is not clinically meaningful (11 studies, 1349 newborns). Skin‐to‐skin contact probably increases infants' blood glucose levels (3 studies, 144 newborns) and may improve their breathing and heart rate (2 studies, 81 newborns). Skin‐to‐skin contact may have little to no effect on the time until the delivery of the placenta (4 studies, 450 women) or maternal bleeding after a vaginal birth (2 studies, 143 women), although the result for maternal bleeding is very uncertain.

What are the limitations of the evidence?

We are moderately confident in most findings, though we are less confident in the results for breathing and heart rate and time to delivery of the placenta, and we are not confident in the result for maternal bleeding. Descriptions and definitions of skin‐to‐skin contact, breastfeeding, other interventions, and standard contact were inconsistent between studies. In addition, the mothers and staff knew which mothers were receiving skin‐to‐skin contact, which could have affected the results. Finally, many studies were small, with fewer than 100 women and newborns participating.

How up to date is this evidence?

This review updates our previous review. The evidence is current to 22 March 2024.

Summary of findings

Summary of findings 1. Summary of findings table ‐ Immediate or early skin‐to‐skin contact compared to standard contact for healthy newborn infants and their mothers.

Immediate or early skin‐to‐skin contact compared to standard contact for healthy newborn infants and their mothers
Patient or population: healthy newborn infants and their mothers Setting: hospital settings in lower‐middle‐income countries (India, Nepal, Pakistan, Vietnam, Zambia), upper‐middle‐income countries (China, Iran, South Africa, Türkiye), and high‐income countries (Chile, Italy, Poland, Russia, Saudi Arabia, Spain, UK, USA) Intervention: immediate or early skin‐to‐skin contact Comparison: standard contact
Outcomes	Anticipated absolute effects* (95% CI)		Relative effect (95% CI)	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
	Risk with standard contact	Risk with immediate or early skin‐to‐skin contact
Exclusive breastfeeding at hospital discharge–1 month postbirth	548 per 1000	745 per 1000 (652 to 855)	RR 1.36 (1.19 to 1.56)	1556 (12 RCTs)	⊕⊕⊕⊝ Moderatea	Immediate or early skin‐to‐skin contact probably increases exclusive breastfeeding at hospital discharge to 1 month postbirth.
Exclusive breastfeeding 6 weeks–6 months postbirth	593 per 1000	818 per 1000 (646 to 1000)	RR 1.38 (1.09 to 1.74)	1135 (11 RCTs)	⊕⊕⊕⊝ Moderateb	Immediate or early skin‐to‐skin contact probably increases exclusive breastfeeding at 6 weeks to 6 months postbirth.
Infant axillary temperature at 30 minutes–2.5 hours postbirth	The mean infant axillary temperature at 30 minutes–2.5 hours postbirth was 36.34 °C	MD 0.28 °C higher (0.14 higher to 0.41 higher)	‐	1349 (11 RCTs)	⊕⊕⊕⊝ Moderatec	Immediate or early skin‐to‐skin contact probably increases infant axillary temperature at 30 minutes to 2.5 hours postbirth, but the difference is not clinically meaningful.
Blood glucose at 75–180 minutes postbirth	The mean blood glucose at 75–180 minutes postbirth was 49.77 mg/dL	MD 10.49 mg/dL higher (8.39 higher to 12.59 higher)	‐	144 (3 RCTs)	⊕⊕⊕⊝ Moderated	Immediate or early skin‐to‐skin contact probably increases blood glucose at 75 minutes to 180 minutes postbirth.
SCRIP score (cardiorespiratory stability) in the first 6 hours postbirth	‐	SMD 1.24 higher (0.76 higher to 1.72 higher)	‐	81 (2 RCTs)	⊕⊕⊝⊝ Lowe	Immediate or early skin‐to‐skin contact may result in a large increase in SCRIP score in the first 6 hours postbirth.
Placental separation time/duration of the third stage of labor	The mean placental separation time/duration of the third stage of labor was 10.1 minutes	MD 2.26 minutes lower (5.04 lower to 0.52 higher)	‐	450 (4 RCTs)	⊕⊕⊝⊝ Lowf	Immediate or early skin‐to‐skin contact may result in little to no difference in placental separation time/duration of the third stage of labor.
Maternal blood loss after vaginal delivery	The mean maternal blood loss after vaginal delivery was 397.86 mL	MD 145.92 mL lower (416.96 lower to 125.11 higher)	‐	143 (2 RCTs)	⊕⊝⊝⊝ Very lowg	Immediate or early skin‐to‐skin contact may result in no difference in the amount of postpartum blood loss after a vaginal delivery.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; MD: mean difference; RR: risk ratio; SMD: standardised mean difference
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
See interactive version of this table: https://gdt.gradepro.org/presentations/#/isof/isof_question_revman_web_452868066674528466.

^a Downgraded 1 level for risk of bias. All trials were rated high risk of bias for blinding of participants, providers and outcome assessors (subjective outcomes) although we felt their knowledge of group assignment was unlikely to influence exclusive breastfeeding. Not downgraded for inconsistency. I² = 62% with random effects model due to 1 outlier. Removing this trial in a sensitivity analysis decreases the heterogeneity to I² = 0% without significantly changing the effect estimate (RR = 1.29, 95% CI = 1.20 to 1.39). 
^b Downgraded 1 level for risk of bias. All trials were rated high risk of bias for blinding of participants, providers and outcome assessors (subjective outcomes) although we felt their knowledge of group assignment was unlikely to influence exclusive breastfeeding. Not downgraded for inconsistency. I² = 87% with random‐effects model due to 1 trial finding slightly higher breastfeeding exclusivity in the control group. Removing this trial in a sensitivity analysis decreases heterogeneity to I² = 43% but the effect estimate remained the same (RR = 1.38, 95% CI = 1.19 to 1.61).
^c Downgraded 1 level for inconsistency. I² = 95% with random‐effects model due to 1 trial finding higher axillary temperature in the control group. However, removing this trial in a sensitivity analysis does not decrease heterogeneity. 
^d Downgraded 1 level for imprecision. The estimate is based on a small sample size.
^e Downgraded 1 level for risk of bias. One trial was rated unclear risk of bias for allocation concealment, 1 high risk of bias for other bias as the results were from an interim analysis, and both had unclear blinding for outcome assessment (objective outcomes). Downgraded 1 level for imprecision. The estimate is based on a small sample size. We also have some reservations regarding the trials' averaging SCRIP scores across repeated measures, as was done in both trials included in this analysis. 
^f Downgraded 1 level for inconsistency. I² = 88% with random‐effects model due to 1 outlier. Removing this trial in a sensitivity analysis decreases the heterogeneity to I² = 0%, effect estimate changes to MD ‐0.90 minutes, 95% CI ‐1.79 to ‐0.02. Downgraded 1 level for imprecision. The 95% confidence interval crosses the line of no effect and into harm. 
^g Downgraded 1 level for risk of bias for attrition. 20 of 54 women randomized to the SSC group (37% and 25 of 59 in the control group (42%) were excluded from the analysis in the Aydin study. Downgraded 1 level for inconsistency. I² = 97% with a random‐effects model. Downgraded 1 level for imprecision. The estimate was based on a small sample size. Also the standard deviations for one trial were estimated from correlations. The 95% confidence interval is wide and crosses the line of no effect and into harm.

Background

Description of the condition

The Baby‐Friendly Hospital Initiative, launched by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF), recommends that maternal‐infant skin‐to‐skin contact (SSC) begin soon after birth and continue, uninterrupted, until after the first breastfeeding [1]. These recommendations are contrary to the 20th‐century industrialization of childbirth, in which mother and infant were routinely separated. However, there is wide variation in the practice of SSC, with low‐income countries reporting the lowest prevalence [2]. Randomized and quasi‐randomized trials have demonstrated a positive effect of SSC on infant transition to extrauterine life, the breastfeeding trajectory, maternal‐infant attachment, and mothers' psychological and physiologic adjustment after birth [3, 4, 5, 6, 7].

Description of the intervention and how it might work

SSC involves placing the dried, naked newborn infant prone on the mother's uncovered chest. For this review, we defined immediate SSC as beginning less than 10 minutes postbirth and early SSC as beginning between 10 minutes and 24 hours postbirth. We compared SSC with any separation, including the infant being held by the mother clothed or wrapped. In SSC, nursing or medical care is provided while the mother‐infant dyad is together skin to skin. With separation, infant care is provided elsewhere, usually on an exam table under a radiant warmer.

Immediately after birth, both the mother and the newborn experience a physiologic and psychologic 'sensitive period'. This 'sensitive period' predisposes or primes mothers and infants to develop a synchronous reciprocal interaction pattern, provided they are together and in intimate contact. The infant must quickly adjust to the stress of being born, the separation from the uterus and placenta, the change in temperature, the expansion of lungs, breathing, and new stimuli—seeing, smelling, hearing, touching, and being touched. When dried and placed in SSC immediately, continuously and without interruption after birth, the newborn infant is warmer, shows less stress, and cries less [8, 9]. When SSC is uninterrupted, the newborn innately progresses through nine behaviors: the birth cry, relaxation, awakening, activity, rest, crawling towards the nipple, familiarization (which includes touching and licking the nipple), suckling at the breast, and falling asleep (the resting stage can happen anytime within and between any of the stages) [10, 11]. While in SSC, the movement of the newborn's legs, knees, and feet massage the mother's uterus, encouraging placental expulsion and the minimization of blood loss. These behaviors are innate, species‐specific, habitat‐ or location‐dependent, and, in early human evolution, essential for survival. SSC also supports attachment theory research, which posits that early interaction between mother and newborn will have a significant positive influence on later socioemotional development and mother‐child relationship functioning [6].

Why it is important to do this review

This is an update of a Cochrane review first published in 2003 and previously updated in 2007, 2012, and 2016 [12, 13, 14, 15]. The purpose of this review is to examine the available evidence on the effects of immediate and early SSC on breastfeeding exclusivity and duration, infant physiology, and maternal outcomes such as pain during episiotomy and laceration repair, blood loss, and the timing of the expulsion of the placenta. Twenty‐six qualifying RCTs on SSC have been published since the 2016 review update. In addition, research has expanded beyond the initial focus on breastfeeding and attachment outcomes to investigate possible neonatal and maternal physiologic effects of SSC. SSC is not resource intensive. This review also asks whether there is a difference in the effect of SSC on breastfeeding exclusivity in high‐ and low‐resource settings.

SSC is increasingly recognized as a clinically significant aspect of care. In the 2018 revision of the WHO/UNICEF Baby‐Friendly Hospital Initiative, Step 4 was updated to reflect the robust ongoing research on SSC. The original (1991) Step 4 was "Help mothers to breastfeed in the first half hour after birth." The 2018 revision changed Step 4 to "Facilitate immediate and uninterrupted skin‐to‐skin contact and support mothers to initiate breastfeeding as soon as possible after birth" [1]. In their systematic review and meta‐analysis published in 2017, Smith and colleagues found that starting breastfeeding between two hours and 23 hours postbirth versus within the first hour postbirth was associated with a 33% increase in risk of neonatal mortality [16]. These data demonstrate the importance of initiating immediate SSC to help facilitate the first breastfeeding soon after birth.

A research and practice guideline on SSC published in 2023 used the WHO guideline development process and reached the conclusion that "immediate, continuous, uninterrupted skin‐to‐skin contact should be the standard of care for all mothers and all babies (from 1000 g with experienced staff if assistance is needed), after all modes of birth. Delaying non‐essential routine care in favor of uninterrupted skin‐to‐skin contact after birth has been shown to be safe and allows for the progression of newborns through their instinctive behaviors." [17].

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.

Secondary objectives

• To assess the effects of immediate or early skin‐to‐skin contact compared with standard contact on the establishment and maintenance of breastfeeding and on maternal and infant physiology among healthy newborn infants and their mothers after cesarean birth.

• To assess the effects of immediate skin‐to‐skin contact compared with early skin‐to‐skin contact on the establishment and maintenance of breastfeeding and on maternal and infant physiology among healthy newborn infants and their mothers.

• To assess the effects of high‐dose skin‐to‐skin contact (< 60 minutes) compared with low‐dose skin‐to‐skin contact (≤ 60 minutes) on the establishment and maintenance of breastfeeding and on maternal and infant physiology among healthy newborn infants and their mothers.

• To assess the effects of immediate or early skin‐to‐skin contact compared with standard contact on the establishment and maintenance of breastfeeding and on maternal and infant physiology among healthy newborn infants and their mothers according to World Bank country income classification (subgroup analysis).

Methods

We followed the Methodological Expectations of Cochrane Intervention Reviews (MECIR) when conducting the review. For reporting, we consulted the Cochrane Handbook for Systematic Reviews of Interventions [18], and we adhered to the PRISMA statement [19].

Changes from the previous review update

For this update, we added three comparisons and nine outcomes and removed 11 outcomes that were listed in the 2016 review update [15]. Supplementary material 8 provides specific details about the changes made and their rationale.

Criteria for considering studies for this review

Types of studies

We included all randomized controlled trials (RCTs) that evaluated active encouragement of immediate or early SSC between mothers and their healthy newborn infants versus usual hospital care. Cluster‐RCTs were eligible, but cross‐over trials and quasi‐randomized trials were ineligible. Quasi‐randomized trials are those where participants are assigned to groups through a process that is not strictly random, such as their date of birth, medical record number, or the day of the week.

Trials reported in abstract form were only eligible for inclusion if there was sufficient information to assess the trial and include data. We listed abstract reports with insufficient information in Supplementary material 5 for one update cycle, considering that a full publication may clarify eligibility.

The potential effects of early SSC on father‐infant attachment are beyond the scope of this review. Maternal feelings about SSC and satisfaction with the birth experience are important and relevant, but evaluation of these outcomes requires more qualitative methods.

Types of participants

We included mothers and their healthy full‐term or late preterm newborn infants (from 34 completed weeks' gestation) who had immediate or early SSC or standard contact. Infants eligible for our targeted trials weighed more than 2500 g, although some healthy late preterm infants weighed less and were not excluded. We excluded infants weighing 1500 g or less because we expected they would have been born before 34 weeks' gestation. We excluded any infant admitted to the neonatal intensive care unit (NICU); eligible infants were healthy enough to stay with their mothers in the postpartum unit.

We included women randomized to SSC after a primary or repeat elective cesarean birth.

We included trials with a subset of infants who did not meet our eligibility criteria if individual participant data were available such that we could exclude these ineligible infants from our analyses.

Types of interventions

Early SSC for term or late preterm infants can be divided into two subcategories, as follows.

• In immediate or very early SSC, the naked infant is placed prone on the mother's bare abdomen or chest less than 10 minutes postbirth. The infant is suctioned while on the mother's abdomen or chest, if medically indicated, thoroughly dried and covered across the back with a prewarmed blanket. To prevent heat loss, the infant's head may be covered with a dry cap that is replaced when it becomes damp. Ideally, all other interventions are delayed until at least one hour postbirth or after the first successful breastfeeding.

• Early SSC can begin anytime between 10 minutes and 24 hours postbirth. The baby is naked (with or without a diaper and cap) and is placed prone on the mother's bare chest between the breasts. The mother may wear a blouse or shirt that opens in front, or a hospital gown worn backwards, and the baby is placed inside the gown so that only the head is exposed. What the mother wears and how the baby is kept warm and what is placed across the baby's back may vary. What is most important is that the mother and baby are in direct ventral‐to‐ventral SSC and the infant is kept dry and warm.

Standard contact includes a variety of conditions: swaddled or dressed infants held in the arms of their mother or another family member, infants placed in open cribs or under radiant warmers, or infants placed in a cot in the mother's room or elsewhere without holding. No infant in the comparison arm could have SSC during study implementation.

Outcome measures

We excluded trials that reported none of our prespecified outcomes.

Critical outcomes

Breastfeeding/lactation

• Exclusive breastfeeding (according to the Index of Breastfeeding Status [IBS]) at hospital discharge to one month postbirth [20, 21]

• Exclusive breastfeeding (according to the IBS) at six weeks to six months postbirth [20, 21]

Infant physiological stability

• Infant axillary temperature in degrees Celsius (°C) at 30 minutes to 2.5 hours postbirth

• Infant blood glucose levels (mg/dL) at 75 minutes to 180 minutes postbirth

• Infant SCRIP score (stability of the cardiorespiratory system—a composite score of heart rate, respiratory status, and arterial hemoglobin oxygen saturation [SaO2], ranging from 0 to 6) during the first six hours postbirth [22, 23]

Maternal physiology

• Placental separation time/duration of the third stage of labor (minutes)

• Maternal blood loss (mL) during/after vaginal or cesarean birth

• Incidence of postpartum hemorrhage

Important outcomes

Breastfeeding/lactation

• Any breastfeeding at one month to four months postbirth

• Duration of any breastfeeding (days)

• Breastfeeding status/level of breastfeeding exclusivity according to the IBS (1: exclusive; 2: almost exclusive; 3: high; 4: medium‐high; 5: medium‐low; 6: low partial; 7: token; 8: weaned [20, 21]) at 1 month postbirth

• Successful first breastfeeding, measured with the Infant Breastfeeding Assessment Tool (IBFAT) or the LATCH score. The IBFAT evaluates four parameters of successful breastfeeding: infant state of arousal or readiness to feed, rooting reflex, latch‐on, and suckling pattern. The infant can receive a score of 0 to 3 on each item for a maximum total score of 12. An IBFAT score greater than 10 is considered effective breastfeeding [24, 25]. The LATCH score evaluates five parameters of successful breastfeeding: Latch, or how effectively the infant grasps the mother's nipple; Audible swallows; the mother's nipple Type; level of breastfeeding Comfort; and Hold, or the amount of assistance the mother needs to position her infant correctly at the breast. The tool uses a numerical score from 0 to 2 to evaluate each of these five parameters for a maximum score of 10 [26].

• Time from birth to first breastfeeding initiation (minutes)

• Maternal breastfeeding confidence measured with the Breastfeeding Self‐efficacy Scale [27]

Infant physiological stability

• Infant transfer to the NICU

• Infant bodyweight change (g)/rate of growth (g/day or kg/day)

Maternal physiology, attitudes, maternal‐infant bonding/attachment

• Maternal pain during episiotomy or perineal laceration repair and up to two hours after, or after cesarean birth, on a scale of 0 to 10, with 10 indicating the worst pain imaginable

• Maternal plasma hemoglobin at two days to three days postbirth

• Maternal salivary cortisol during SSC or standard contact and up to one day postbirth

• Maternal anxiety at two hours to three days postbirth, measured with the state anxiety scale from the State Trait Anxiety Inventory (STAI). The state anxiety scale is a 20‐item instrument that measures how the individual feels in the present moment with a possible range of scores from 20 to 80, with higher scores indicating more anxiety [28].

• Maternal perceptions of bonding with her infant and sensitivity to her infant's cues at 12 months postbirth, measured using the Parent‐Child Early Relational Assessment (PCERA). The PCERA has eight subscales evaluating maternal and infant behavior and interaction. The dyadic mutuality and reciprocity subscale of the PCERA has four items and measures maternal sensitivity to her infant's cues such as her affect, enthusiasm, reciprocity, and state similarity. Each item is scored on a 5‐point Likert scale with values of 1 to 2 indicating an area of concern, 3 an area of some concern, and 4 to 5 an area of strength; the minimum score is 4 and the maximum score is 20 [29, 30].

• Mother's preference for the same postdelivery care in the future

Search methods for identification of studies

Supplementary material 1 presents all search methods. The search time frame was from 17 December 2015 (the search date for the 2016 review update) to 22 March 2024. We consulted the Technical Supplement to Chapter 4 of the Cochrane Handbook for Systematic Reviews of Interventions to develop the search strategies [31].

Electronic searches

An Information Specialist from the Cochrane Central Executive Team searched the following databases on 22 March 2024.

• Cochrane Central Register of Controlled Trials (CENTRAL; 2024, Issue 3), in the Cochrane Library (searched 22 March 2024)

• MEDLINE via OvidSP (17 December 2015 to 22 March 2024)

• Embase via OvidSP (17 December 2015 to 22 March 2024)

• Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCO host (17 December 2015 to 22 March 2024)

We also searched the following trials registers in July 2025.

• US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (https://www.clinicaltrials.gov/; searched 1 July 2025)

• WHO International Clinical Trials Registry Platform (https://trialsearch.who.int/; searched 6 July 2025)

There were no restrictions related to publication status or language.

Searching other resources

We searched the reference lists of retrieved studies and asked members of our review author group to identify additional studies that might be eligible for our review.

We used Zotero [32] to track retractions of published studies through its integration with the Retraction Watch database. If any study in our Zotero library had been retracted, we would have received an alert. At present, Zotero does not keep track of errata or corrigenda.

Data collection and analysis

We made some changes to the methods from the last version of this review [15].

In this update, we used the methods described in successive sections to assess the 26 new trials identified in the 2024 search.

Selection of studies

Two review authors (EM and KC) independently assessed for inclusion all references identified through the searches and used Zotero for reference management [32]. We recorded reasons for study exclusion. We resolved any disagreement through discussion or, if required, by consulting a third review author. We used the PRISMA 2020 statement and flow diagram to document the trial screening and selection process [19].

Data extraction and management

We updated a form previously used to extract data. KC divided the review author team into three groups based on their clinical area of interest/expertise (breastfeeding, maternal care, and neonatal care) and distributed the articles among the three groups. Each article was reviewed independently by at least two members of its assigned group. Discrepancies were resolved through discussion or, if required, consultation with a third review author (EM or KC). Two review authors (AB and KB) entered study characteristics, risk of bias assessments, and outcome data for analysis into RevMan [33], and another two review authors (EM and KC) checked the data for accuracy.

We tried to contact study authors by email to request further information where necessary.

We extracted the following data from individual trials.

• Mothers' sociodemographic characteristics (age, ethnicity, education, employment status)

• Infant characteristics (gestational age, birthweight, sex)

• Number of mothers eligible, enrolled, and included in outcome analyses

• Details of SSC (timing after birth, frequency, duration, interruptions, breastfeeding assistance provided)

• Details of standard contact/control conditions

• Country and delivery setting

• Outcome data (mean with standard deviation [SD] or number of events/participants) for each eligible outcome included in the trials

• Study funding and author conflicts of interest

Risk of bias assessment in included studies

At least two review authors independently assessed the risk of bias in the trials assigned to their team using the original Cochrane risk of bias tool (RoB 1), which covers the following domains [34].

• Random sequence generation (selection bias)

• Allocation concealment (selection bias)

• Blinding of participants and personnel (performance bias)

• Blinding of outcome assessment (detection bias)

• Incomplete outcome data (attrition bias)

• Selective outcome reporting (reporting bias)

• Other possible sources of bias

Other biases included those that might influence generalizability, such as the number of mothers who were approached to participate in the study but declined and baseline between‐group differences in social or demographic characteristics. We also noted any co‐interventions that could influence outcomes, and whether the researchers provided nursing care in the SSC group and hospital staff in the usual care group. If present, this information was added to the assessment. We judged the trials at low, high, or unclear risk of bias for each domain. For this update, we analyzed performance bias and detection bias separately for objective and subjective outcomes. Any disagreements were resolved by discussion or by involving a third assessor (EM or KC).

Measures of treatment effect

For dichotomous data, we presented results as a summary risk ratio (RR) with its 95% confidence interval (CI).

For continuous data, we used the mean difference (MD) with its 95% CI if outcomes were measured in the same way across trials. We used the standardized mean difference (SMD) with its 95% CI to combine continuous data from trials that measured the same outcome but used different methods [35]. When included studies reported skewed data as medians and interquartile ranges, we described the results narratively.

Unit of analysis issues

We included one cluster‐randomized trial in this review but opted not to formally adjust for the cluster design. We considered it reasonable to combine the results from both individual and cluster‐randomized trials if there was little heterogeneity between the study designs and if the type of randomization was unlikely to have influenced the intervention effect. We acknowledged heterogeneity in the randomization unit and performed a sensitivity analysis to investigate the effects of the randomization unit.

Cross‐over trials were not eligible for inclusion in this review.

Dealing with missing data

We attempted to contact study authors by email to obtain missing numerical outcome data.

For included studies, we noted levels of attrition.

Reporting bias assessment

We investigated reporting biases (such as publication bias) using funnel plots where meta‐analyses included 10 or more studies. If visual assessment of the funnel plot suggested asymmetry, we performed exploratory analyses to investigate it.

Synthesis methods

We carried out statistical analysis using RevMan [33], following the guidance in Chapter 10 of the Cochrane Handbook for Systematic Reviews of Interventions [36]. We used fixed‐effect meta‐analysis to combine data where it was reasonable to assume that studies were estimating the same underlying treatment effect (i.e. where trials were examining the same intervention, and the trials' populations and methods were judged sufficiently similar).

If there was sufficient clinical heterogeneity to suggest that the underlying treatment effects differed between trials, or if we detected substantial statistical heterogeneity, we used random‐effects meta‐analysis to produce an overall summary. However, we only did this if we judged that an average treatment effect, despite the differences between trials, would still be a clinically meaningful result. We treated the random‐effects summary as the average of the range of possible treatment effects, and we discussed the clinical implications of treatment effects differing between trials. If the average treatment effect was not clinically meaningful, we planned not to combine trials. Where we used random‐effects analyses, the results were presented as the average treatment effect with 95% CIs and the estimates of Tau² and I².

We assessed statistical heterogeneity in each meta‐analysis using the Tau², I², and Chi² statistics. We regarded heterogeneity as substantial if the I² value was greater than 40% and either the Tau² was greater than 0 or there was a low P value (less than 0.10) in the Chi² test for heterogeneity. If we identified substantial heterogeneity (above 40%), we provided possible reasons for this in the text. We also explored heterogeneity through prespecified subgroup or sensitivity analyses.

If we were unable to combine the results in a meta‐analysis, we provided a narrative summary.

Investigation of heterogeneity and subgroup analysis

If we identified substantial heterogeneity, we considered whether an overall summary was meaningful. If it was, we combined data using a random‐effects analysis.

We carried out subgroup analyses to explore the influence of the following factors, even where there was no heterogeneity.

• Time of initiation of SSC (immediate or early)

• Dose (duration of SSC)

• World Bank classification of country income level

We performed subgroup analysis of the following outcomes.

• Exclusive breastfeeding at hospital discharge to one month postbirth

• Exclusive breastfeeding at six weeks to six months postbirth

• Any breastfeeding at one month to four months postbirth

• Duration of any breastfeeding

• Infant axillary temperature at 30 minutes to 2.5 hours postbirth

We assessed subgroup differences using interaction tests available within RevMan [33]. We reported the results of subgroup analyses, quoting the Chi² statistic and P value, and the interaction test I² value.

Equity‐related assessment

Low‐income countries have the lowest uptake of SSC [2]. SSC is a low‐cost intervention that, according to the results of previous systematic reviews, is beneficial for both mother and infant. For this reason, we added a subgroup analysis of the effect of SSC on breastfeeding and infant axillary temperature outcomes according to the World Bank classification of country income level. Breastfeeding has a substantial impact on infant health, especially in low‐income countries where safe breast milk substitutes are often not readily available.

Sensitivity analysis

We conducted sensitivity analysis to assess the effects of outliers, heterogeneity, and intracluster correlation coefficients on the results.

We moved unused methods regarding cluster‐RCTs, missing data, and sensitivity analysis to Supplementary material 9.

Certainty of the evidence assessment

For this update, we assessed the certainty of the evidence using the GRADE approach, as outlined in the Grade Book (https://book.gradepro.org/) and in Chapter 14 of the Cochrane Handbook for Systematic Reviews of Interventions [37]. The GRADE approach uses five considerations (risk of bias, consistency of effect, imprecision, indirectness, and publication bias) to assess the certainty of the body of evidence for each outcome. The evidence can be downgraded from high certainty by one level for serious (or by two levels for very serious) limitations related to each of these considerations. Our GRADE assessment covered the following outcomes within the main comparison of immediate or early SSC versus standard contact for mothers and their healthy infants.

• Exclusive breastfeeding at hospital discharge to one month postbirth

• Exclusive breastfeeding at six weeks to six months postbirth

• Infant axillary temperature at 30 minutes to 2.5 hours postbirth

• Infant blood glucose level at 75 minutes to 180 minutes postbirth

• Infant SCRIP score during the first six hours postbirth

• Placental separation time/duration of the third stage of labor

• Maternal blood loss after vaginal delivery

Four study authors (EM, KC, AB and KB) independently assessed the certainty of the evidence and discussed their findings. They resolved any disagreements with guidance from a Cochrane evidence synthesis development editor.

We used GRADEpro GDT [38] to import data from RevMan [33] and create a summary of findings table.

Consumer involvement

Consumers were not specifically involved in this review due to limited resources, although there are consumers, providers, and researchers in the review author team.

Results

Description of studies

Supplementary material 6 contains all the comparisons and analyses conducted for this review update. Supplementary material 7 contains the complete data package.

Results of the search

Figure 1, the study flow diagram, illustrates the study screening and selection process for this update. Supplementary material 1 describes the detailed search strategy.

1.

PRISMA flow diagram for updated systematic reviews, presenting the results of study identification, record screening, and full‐text assessment.

Footnotes
GA: gestational age; KMC: kangaroo mother care; RCT: randomized controlled trial; SSC: skin‐to‐skin contact.

We found 2819 records through database searching, and five records from other sources. We screened 1813 records after removing duplicates and excluded 1738 as irrelevant. We assessed 65 studies (75 full‐text articles) for eligibility and excluded 39. Reasons for exclusion were preterm infants born before 34 weeks' gestation (14 studies), ineligible study design (7 studies), ineligible outcomes (6 studies), ineligible intervention (4 studies), long‐term SSC at five weeks to 12 weeks postbirth (4 studies), SSC beginning more than 24 hours postbirth (2 studies), abdominal SSC compared with kangaroo mother care (1 study), and study retracted (1 study). We added eight of these excluded studies to the characteristics of excluded studies table (Supplementary material 3).

This review update included 26 new trials reported in 32 articles (Agudelo 2021 [39, 40, 41, 42]; Al‐Morbaty 2017 [43]; Aydin 2022 [44]; Crenshaw 2019 [45]; Gregson 2016 [46]; Gunduz 2023 [47]; Hinduja 2014 [48]; Karimi 2014 [49, 50]; Kollmann 2017 [51]; Liao 2020 [52]; Mulupuru 2019 [53]; Oksuz 2021 [54]; Perez‐Jimenez 2023 [55]; Pouraboli 2019 [56]; Raj Kumawat 2024 [57]; Ramani 2018 [58, 59]; Sharma 2016 [60]; Solt 2022 [61]; Taechavichitpisal 2023 [62]; Tosun 2020 [63]; Turan 2019 [64]; Walsh 2021 [65]; Yuksel 2016 [66]; Zafran 2019 [67, 68]; Zhang 2023 [69]; Zou 2022 [70]). We also found two new publications to add to previously included studies: a new report for Nimbalkar 2014 [71, 72, 73] and a conference abstract for Thukral 2012 [74, 75]. We found two ongoing studies, which we listed in the ongoing studies table (Supplementary material 5). One study from an informal top‐up search of MEDLINE, Embase, and CINAHL in June 2025 is awaiting classification (Supplementary material 4).

The 2016 review had 46 included studies (87 reports), three studies awaiting classification (three reports), and one ongoing study (one report). We brought forward 43 previously included studies to include in this update, removed three previously included studies (three reports), and removed two records from two previously included studies. One study (one report) previously listed as awaiting classification was included in this update (Ramani 2018), whereas the other two studies were excluded along with the ongoing study. In total, this update included 69 studies (116 articles), of which 56 contributed to the meta‐analysis. For six studies, no usable data were available (Curry 1982 [76, 77, 78]; Hales 1977 [79]; Kastner 2005 [80, 81]; McClellan 1980 [82]; Svejda 1980 [83]).

Included studies

This review update included 69 trials. Table 2 presents the key characteristics of the participants, interventions, synthesis methods, and outcome measurement time points. Supplementary material 2 provides a detailed description of the characteristics of each included study. Thirty‐three studies provided information about their funding sources, six were not funded, and 30 made no mention of funding. In 27 studies, the authors stated they had no conflicts of interest to declare, while 42 studies provided no information about conflicts of interest.

1. Overview of included studies and synthesis table illustrating key study characteristics, outcomes, and analysis methods.

Comparison: immediate or early skin‐to‐skin contact versus standard contact
Study ID Country (income)	SSC timing and dose	Control: separation or holding	n SSC group/control group	Type of birth, gestation	Outcome domains: specific outcome measures (time point of measurement)	Synthesis method
Al‐Morbaty 2017 Saudi Arabia (HI)	?	?	14/14	V, T	Maternal physiology: placental separation time (PB)	MA
Anderson 2003 USA (HI)	I, HD	S or H	16/15	V, LPT	Breastfeeding: exclusive BF (hospital DC); exclusive BF (3 months PB); any BF (6 weeks PB)	MA
Armbrust 2016 Germany (HI)	I, HD	S	102/103	CS, T	Breastfeeding: any BF (1 month PB) Maternal physiology: estimated blood loss (intraoperative)	MA for any BF; summary (median) for estimated blood loss
Aydin 2022 Türkiye (UMI)	I, LD	S	54/59	V, T	Maternal physiology: pain after episiotomy or perineal repair (2 hours after repair); blood loss, vaginal birth (intrapartum/1st 24 hours postpartum)	MA for pain, summary for blood loss
Beiranvand 2014 Iran (UMI)	E, LD	S	48/48	CS, T	Breastfeeding: BF success by IBFAT score (1st BF)	MA
Bergman 2004 South Africa (UMI)	I, HD	S	20/14	V, LPT	Infant physiology: SCRIP score (1st 6 hours) NICU admission (PB)	MA
Bystrova 2003 Russia (HI)	E, HD	H	44/44	V, T	Infant physiology: axillary temp (30 min PB) Maternal attachment: PCERA (12 months PB)	MA for axillary temp, summary for PCERA
Carfoot 2004 UK (HI)	I, HD	H	14/14	V or CS, T	Breastfeeding: any BF (4 months PB); exclusive BF (4 months PB); BF success BAT (1st BF)	MA
Carfoot 2005 [145] UK (HI)	I, LD	H	102/102	V, T	Breastfeeding: any BF (4 months PB); BF success by BAT (1st BF) Infant physiology: axillary temp (1 hour PB) Maternal attitudes: preference for same postdelivery care (4 months PB)	MA
Carlsson 1978 [146, 147, 148, 149, 150] Sweden (HI)	I, LD	2 groups: S or H	22/20 (control G1)/20 (control G2)	V, T	Maternal attachment: contact and non‐contact behavior (Day 2 and 4 PB)	Summary
Christensson 1992 [151] Spain (HI)	I, HD	S	25/25	V, T	Infant physiology: axillary temp (90 min PB); blood Glucose (90 min PB)	MA
Christensson 1995 [152, 153] Spain (HI)	I, HD	2 groups: S 90 min or S 45 min	15/14 (control G1)/15 (control G2)	V, T	Infant physiology: axillary temp (90 min PB)	MA
Chwo 1999 Taiwan (HI)	E, HD	S	17/17	V or CS, LPT	Infant physiology: bodyweight change (Day 14 PB)	MA
Curry 1982 USA (HI)	I, LD	H	9/11	V, T	Maternal attachment: maternal attachment behaviors (36 hours, 3 months PB)	Summary
De Chateau 1977 Sweden (HI)	E, LD	S or H	22/20 (control G1)/20 (control G2)	V, T	Breastfeeding: BF duration (3 months PB)	MA
Fardig 1980 [154] USA (HI)	I, LD	S or H	17/17 (control G1)/17 (control G2)	V, T	Infant physiology: axillary temp (30 min PB)	MA
Girish 2013 India (LMI)	I, LD	S	50/50	V, T	Breastfeeding: BF success by IBFAT score (1st BF)	MA
Gouchon 2010 Italy (HI)	E, HD	S	17/17	CS, T	Breastfeeding: exclusive BF (hospital DC); exclusive BF (3 months); BF success by IBFAT (1st BF)	MA
Gunduz 2023 Türkiye (UMI)	I, ?	?	42/42	V, T	Maternal physiology: placental separation time (PB) Breastfeeding: timing of 1st BF; BF success by LATCH (1st BF)	MA
Hales 1977 Guatemala (UMI)	I, LD	S	20/20 (delayed SSC)/20 (separation)	V, T	Maternal attachment: maternal affectionate, proximity and caretaking behavior (36 hours PB)	Summary
Hinduja 2014 India (LMI)	I, HD	S	30/30	V, T	Infant physiology: axillary temp (60 min PB)	MA
Karimi 2014 Iran (UMI)	I, HD	S	57/57	V, T	Breastfeeding: exclusive BF (Day 28 PB); BF success by IBFAT (1st BF); timing of 1st latch (1st BF); BF confidence (Day 28 PB)	MA
Kastner 2005 Germany (HI)	?, LD	H	31/26	V, T	Maternal attachment: 4 mother‐child relationship scales (Delivery room; Puerperium; Home visit) (5–6 weeks PB)	Summary
Khadivzadeh 2009 [155, 156, 157, 158, 159, 160, 161, 162] Iran (UMI)	I, HD	S then H	47/45	V, T	Breastfeeding: BF success by IBFAT (1st BF)	MA
Kollmann 2017 Austria (HI)	I, ?	S	17/18	CS, T	Maternal physiology: salivary cortisol (25 min PB)	Summary (median, IQR)
Liao 2020 China (UMI)	E,?	S	39/39	V, T	Breastfeeding: exclusive BF (42 days PB); BF success, measurement method? (1st BF)	MA
Luong 2016 Vietnam LMI	I, HD	S	24/26	V, LPT	Infant physiology: SCRIP score (180 min PB); blood glucose (180 min PB); axillary temp (180 min PB)	MA
Mahmood 2011 Pakistan (LMI)	I, LD	S	92/91	V, T	Breastfeeding: exclusive BF (1 month PB); BF success by IBFAT (1st BF) Maternal attitudes: preference for same postdelivery care	MA
Marin 2010 Spain (HI)a	I, HD	H	137/137	V, T or LPT	Breastfeeding: exclusive BF (hospital DC) Infant physiology: NICU transfer (hospital DC) Maternal attitudes: state anxiety (hospital DC) Maternal physiology: pain (during episiotomy repair); placental separation (PB)	MA
Mazurek 1999 [163] Poland (HI)	I, HD	S	22/22 (swaddling)/22 (separation)	V, T	Infant physiology: blood glucose (75 min PB)	MA
McClellan 1980 USA (HI)	E, LD	S then H	20/20	CS, T	Maternal attachment: observation of maternal behavior (PP day 1 or 2)	Summary
Mizuno 2004 [164] Japan (HI)	I, HD	S	30/30	V, T	Breastfeeding: BF duration	MA
Moore 2005 USA (HI)	I, HD	H	10/10	V, T	Breastfeeding: BF status (1 month PB); BF success by IBFAT (1st BF) Infant physiology: bodyweight change (Day 14 PB)	MA
Mulupuru 2019 India (LMI)	I, LD	S then H	100/100	V, T	Breastfeeding: exclusive BF (6 weeks PB)	MA
Nahidi 2011 Iran (UMI)	I, ?	S	40/40	V, T	Maternal attitudes: preference for same postdelivery care (end of 1st BF)	MA
Nasehi 2012 Iran (UMI)	E, HD	S	54/56	CS, T	Breastfeeding: exclusive BF (3 months PB)	MA
Nimbalkar 2014 India (LMI)	E, HD	H	50/50	V, LPT+T	Breastfeeding: exclusive BF (6 months PB) Infant physiology: axillary temp (2 hours PB)	MA
Nolan 2009 USA (HI)	E, LD	S	25/25	CS, T	Breastfeeding: any BF (1 month PB) Maternal physiology: pain (4 hours PB)	MA
Norouzi 2013 Iran (UMI)	?, LD	?	30/30/30 CS, T		Maternal attitudes: state anxiety (6 hours PB)	MA
Oksuz 2021 Türkiye (UMI)	I, HD	S then H	56/56	V, T	Breastfeeding: BF success by LATCH (1st BF); timing of 1st latch (1st BF)	MA
Perez‐Jimenez 2023 Spain (HI)	E, HD	S	40/40	CS, T	Breastfeeding: exclusive BF (1 month PB); BF success (1st BF) Maternal physiology: pain (DC recovery to PP); plasma Hgb (Day 3 PB)	MA
Pouraboli 2019 Iran (UMI)	E, LD	S	40/40	CS, T	Breastfeeding: exclusive BF (hospital DC)	MA
Punthmatharith 2001 Thailand (UMI)	E, LD	H	97/99	V, T	Breastfeeding: BF status (4 weeks PB)	MA
Ramani 2018 Zambia (LMI)	I, LD	S then H?	101/102	V, T	Infant physiology: axillary temp (1 hour PB)	MA
Sharma 2016 India (LMI)	I, LD	S	100/100	V, T	Breastfeeding: exclusive BF (6 weeks PB) Infant physiology: axillary temp (30 min PB) Maternal physiology: pain (during episiotomy repair)	MA
Shiau 1997 Taiwan (HI)	E, HD	S	29/29	V or CS, T	Breastfeeding: any BF; BF duration (Day 28 PB); BF status (Day 28 PB) Maternal attitudes: state anxiety (3 hours PB)	MA
Solt 2022 Türkiye (UMI)	I, LD	S?	50/50 (music medicine)/50 (controls)	V, T	Maternal physiology: pain after episiotomy (immediately after repair) Maternal attitudes: state anxiety (in delivery 15–20 min after repair)	MA
Sosa 1976a Guatemala (UMI)	E, LD	S	30/30	V, T	Breastfeeding: any BF; BF duration (3 months PB)	MA
Sosa 1976b Guatemala (UMI)	E, LD	S	34/34	V, T	Breastfeeding: any BF; BF duration (3 months PB)	MA
Sosa 1976c Guatemala (UMI)	E, LD	S	20/20	V, T	Breastfeeding: any BF; BF duration (3 months PB)	MA
Srivastava 2014 India (LMI)	E, HD	H	150/148	V, T	Breastfeeding: exclusive BF (Day 4 or 5 PB); exclusive BF (6 weeks PB); BF success by IBFAT (1st BF) Infant physiology: axillary temp (2 hours PB)	MA
Svejda 1980 USA (HI)	E, LD	S	15/15	V, T	Maternal attachment: maternal affectionate, proximity and caretaking behavior (36 hours PB)	Summary
Syfrett 1993 USA (HI)	E, HD	S	4/4	V, LPT	Breastfeeding: any BF; BF duration (2 months PB)	MA
Taechavichitpisal 2023 Thailand (UMI)	I, LD	S	30/30	V, T	Maternal physiology: pain after episiotomy (1 hour PB)	Summary (median, IQR)
Thomson 1979 [165] Canada (HI)	E, LD	S	15/15	V, T	Breastfeeding: any BF (2 months PB)	MA
Thukral 2012 India (LMI)	I, HD	H	20/21	V, T	Breastfeeding: exclusive BF (48 hours PB); exclusive BF (6 weeks PB)	MA
Tosun 2020 Türkiye (UMI)	?, LD	?	40/40	V, T	Maternal physiology: blood loss, vaginal birth (postpartum 1st 24 hours)	Summary (median, IQR)
Turan 2019 Türkiye (UMI)	I, LD	S	32/32	V, T	Maternal physiology: placental separation time (PB); pain postpartum (15 min PB)	MA for placental separation time; summary (median, IQR) for pain
Vaidya 2005 Nepal (LMI)	E, LD	H	44/48	V or CS, T	Breastfeeding: any BF (2–4 months PB); exclusive BF (4–6 months PB)	MA
Villalon 1992 Chile (HI)	I, HD	S	59/60	V, T	Breastfeeding: exclusive BF (14 days PB) Infant physiology: axillary temp (2 hours PB)	MA
Yuksel 2016 Türkiye (UMI)	I, LD	S	45/45	CS, T	Maternal physiology: pain after CS (48 hours after CS)	MA
Zafran 2019 Israel (HI)	I, LD	S	108/106	CS, T	Breastfeeding: exclusive BF (hospital DC) Maternal physiology: PPH (estimated by surgeon); pain (end of CS); pain (1st 24 hours PB); plasma Hgb (2–3 days PB) Infant physiology: NICU admission	MA for exclusive BF, pain, plasma Hgb and NICU admission; summary for PPH
Zou 2022 China (UMI)	I, HD	S? SSC began after repair	60/60	V, T	Maternal physiology: pain after episiotomy (immediately after repair)	MA
Comparison: Immediate versus early skin‐to‐skin contact
Study ID Country (income)	Immediate SSC dose	Control: separation or holding	n SSC group/control group	Type of birth, gestation	Outcome domains: specific outcome measures (time point of measurement)	Synthesis method
Agudelo 2021 Colombia (UMI)	LD	?	148/149	V, T	Breastfeeding: exclusive BF (1st month); exclusive BF (6 months)	MA
Crenshaw 2019 USA (HI)	HD	?	20/20	CS, T	Breastfeeding: exclusive BF (hospital DC) Infant physiology: axillary temp (In recovery room) Maternal physiology: salivary cortisol (PP 2 hours after admission)	MA for exclusive BF and axillary temp; summary (1 study) for salivary cortisol
Gregson 2016 England, UK (HI)	HD	H	182/187	CS, T	Breastfeeding: exclusive BF (10 days PB); exclusive BF (6 weeks PB) Infant physiology: NICU admission	MA
Walsh 2021 USA (HI)	LD	?	21/26	V, LPT	Infant physiology: NICU admission; blood glucose (30 min PB); axillary temp (30 min PB)	MA for NICU admission; summary for blood glucose, axillary temp (1 study per outcome)
Comparison: High‐dose versus low‐dose skin‐to‐skin contact
Study ID Country (income)	High‐dose SSC group/low‐dose SSC group (n)			Type of birth, gestation	Outcome domains: specific outcome measures (time point of measurement)	Synthesis method
Raj Kumawat 2024 India (LMI)	99/99			V, LPT or T	Breastfeeding: exclusive BF (60 +12 hours PB); exclusive BF (10 weeks PB)	Summary for 60 +12 hours PB, MA for 10 weeks PB
Zhang 2023 China (UMI)	176 (30 min SSC)/146 (60 min SSC)/164 (90 min SSC)/173 (control)			CS, T	Breastfeeding: exclusive BF (hospital DC) Infant physiology: NICU admission Maternal physiology: intraoperative blood loss (Intraoperative); postoperative blood loss (24 hours postoperatively); plasma Hgb (hospital DC)	MA for exclusive BF; summary for NICU admission, intraoperative and postoperative blood loss and plasma Hgb (1 study per outcome)

^aAll studies were RCTs; this study was a cluster‐RCT with randomization by pediatrician.

BAT: breastfeeding assessment tool; BF: breastfeeding; CS: cesarean section; DC: discharge; E: early skin‐to‐skin contact (> 10 minutes after birth); G: group; HI: high income (income classification determined by the World Bank); H: newborn held swaddled or clothed or placed in bed next to mother; HD: high dose of skin‐to‐skin contact (> 60 minutes); Hgb: hemoglobin; I: immediate skin‐to‐skin contact (< 10 minutes after birth); IBFAT: Infant Breastfeeding Assessment Tool; IQR: interquartile range; LATCH: latch, audible swallowing, type of nipple, comfort, and hold; LD: low dose of skin‐to‐skin contact (< 60 minutes); LMI: lower‐middle income (income classification determined by the World Bank); LPT: late preterm (34 weeks 0 days–36 weeks 6 days of gestation); MA: meta‐analysis; min: minute(s); n: number of mother‐infant pairs: NICU: neonatal intensive care unit; PB: postbirth; PCERA: Parent‐Child Early Relational Assessment; PP: postpartum; PPH: postpartum hemorrhage; RCT: randomized controlled trial; S: newborn separated from mother; SCRIP: stability of the cardiorespiratory system in preterm infants; T: term infant (37–42 weeks of gestation); temp: temperature; UMI: upper‐middle income (income classification determined by the World Bank); V: vaginal birth; ?: info not provided.

We included unpublished data or clarifications from study authors for five trials (Armbrust 2016 [84]; Girish 2013 [85]; Luong 2016 [86]; Nimbalkar 2014; Perez‐Jimenez 2023).

Characteristics of the studies

Thirty‐two trials were conducted in high‐income countries, 25 in upper‐middle‐income countries, 12 in lower‐middle‐income countries, and none in low‐income countries (https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups). The lower‐middle‐income countries were India, Nepal, Pakistan, Vietnam, and Zambia. All but three studies were published as full‐text articles between 1976 and 2024. Punthmatharith 2001 [87] and Shiau 1997 [88, 89] were unpublished doctoral dissertations, and Syfrett 1993 [90, 91] was an unpublished master's thesis. Only one trial was a cluster‐RCT, with randomization by pediatrician (Marin 2010 [92]).

Population

The 69 trials included 7290 mother‐infant pairs. Fifty‐nine trials included only healthy full‐term infants. Six trials included healthy late preterm infants who were assigned to the normal newborn nursery or neonatal unit (Anderson 2003 [93, 94, 95]; Bergman 2004 [22, 96, 97]; Chwo 1999 [98, 99]; Luong 2016; Syfrett 1993; Walsh 2021). Marin 2010, Nimbalkar 2014 and Raj Kumawat 2024 included both term and late preterm infants, while for Luong 2016 we included a subset of late preterm infants with low birthweight (unpublished data). Fifteen studies were conducted with healthy mother‐infant dyads after a primary or repeat elective cesarean birth (Armbrust 2016; Beiranvand 2014 [100]; Crenshaw 2019; Gouchon 2010 [101]; Gregson 2016; Kollmann 2017; McClellan 1980; Nasehi 2012 [102]; Nolan 2009 [103]; Norouzi 2013 [104]; Perez‐Jimenez 2023; Pouraboli 2019; Yuksel 2016; Zafran 2019; Zhang 2023).

Interventions

Duration of SSC ranged from approximately 15 minutes (Svejda 1980; Vaidya 2005 [105]; Yuksel 2016) to a mean of 37 hours of continuous SSC (Syfrett 1993).

We evaluated SSC versus standard contact by time of initiation (immediate or early) in a subgroup analysis. Forty‐three trials started SSC immediately after birth, whereas 22 provided only early contact and had considerable differences in timing. Many infants went to their mothers after an initial assessment that was longer than 10 minutes; the exact timing was not always described.

We also compared SSC versus standard contact in a subgroup analysis by dose of SSC (low or high). Thirty‐three trials offered infants 60 minutes or less of SSC.

Four trials evaluated immediate versus early initiation of SSC (Agudelo 2021; Crenshaw 2019; Gregson 2016; Walsh 2021), and two trials compared high‐dose with low‐dose SSC (Raj Kumawat 2024; Zhang 2023).

Control groups

There were substantial differences between trials in the amount of separation that occurred in the control group. Some infants were removed from their mothers immediately after birth and reunited up to 24 hours later. Some mothers held their swaddled infants for several minutes or more soon after birth and then were separated from their infants. Many trials did not report when the control mothers and infants were reunited or the length of initial contact. The control group in several trials received multiple interventions, including some that may interfere with breastfeeding (e.g. baths and physical assessment).

Excluded studies

A total of 151 studies have been excluded from this review (previous versions and this update) during full‐text analysis. In this update, we excluded 39 studies. Figure 1 provides the reasons for exclusion. The characteristics of excluded studies table lists 24 studies, eight of which we added in this update (Supplementary material 3). The most common reason for exclusion was an unclear description of the intervention, so we could not determine if it was SSC (6 studies). Where possible, we contacted the study authors for clarification. Other reasons were that the study was not an RCT (5 studies), the early contact was not SSC (4 studies), the comparison was not part of our review (3 studies), or the study evaluated none of our prespecified outcomes (2 studies). In four studies, it was unclear how many women received the intervention they were randomized to, because the researchers let the mothers decide.

Ongoing studies

In NCT06011096 [106], 126 primiparous pregnant women were randomized to SSC or a standard contact control group in the clinic of Erzurum City Hospital, Türkiye. In the SSC group, the infant was placed on the mother's chest 60 seconds to 90 seconds postbirth, and breastfeeding was attempted. After approximately one hour, the umbilical cord was clamped, and the infant was placed under a radiant heater and routine care was initiated. In the standard contact group, the umbilical cord was clamped immediately after birth and the infant was taken to the radiant warmer for routine care. Outcomes included placental separation and delivery time, amount of postpartum bleeding, maternal hemoglobin and hematocrit six hours postbirth, and postpartum comfort.

In NCT06514352 [107], 192 women delivering at Tarsus State Hospital Maternity Room in Türkiye were randomized to one of four groups: SSC immediately after birth, very early SSC, early SSC, or control. In the immediate SSC group, the newborn was placed on the mother's chest immediately (without cord clamping) for an average of 60 minutes. All routine practices (except weight measurement) were performed on the mother's chest. In the very early SSC group, SSC began within the first 30 to 40 minutes postbirth for an average of 60 minutes. Control care involved the hospital's routine practices. Primary outcomes were LATCH scores at 12 hours and 24 hours and newborn stress.

Risk of bias in included studies

No trial met all criteria for low risk of bias, primarily due to lack of blinding in trials with subjective outcomes. Many included studies had unclear reporting for one or more domains. Several studies had a high risk of bias for incomplete reporting of allocation concealment, attrition, or other sources of bias, including multiple co‐interventions or baseline differences in important potential or known covariates such as socioeconomic status. Trials were better at reporting randomization methods. Figure 2 presents an overall summary of the risk of bias for all studies, and Figure 3 presents separate risk of bias judgments for each study.

2.

'Risk of bias' graph: review authors' judgments about each risk of bias item presented as percentages across all included studies.

3.

'Risk of bias' summary: review authors' judgments about each risk of bias item for each included study.

Sequence generation (selection bias)

In 42 studies, trialists described clear and appropriate methods for generating the randomization sequence (low risk of bias). We rated the other 27 trials at unclear risk of bias for this domain because they did not describe the methods used to generate the randomization sequence.

Allocation concealment (selection bias)

W considered 30 trials at low risk of bias for allocation concealment because they used sequential, sealed opaque envelopes or computer‐generated random lists. We judged two trials at high risk of bias for allocation concealment because the researchers used an open table of random numbers (De Chateau 1977 [108, 109, 110, 111, 112, 113, 114, 115, 116]; McClellan 1980). The remaining 37 trials provided insufficient information about allocation concealment. Some of these trials only reported that women were randomly assigned to groups.

Blinding (performance bias and detection bias): subjective outcomes

Performance bias

Because the intervention clearly differed from control conditions, and blinding of participants and personnel was not possible, we assessed all trials with subjective outcomes at high risk of performance bias for these outcomes. In our GRADE assessment, we downgraded all subjective outcomes due to lack of adequate blinding.

Most women and staff were aware of the intervention, and this awareness may have altered women's behavior and responses to questions and influenced the content and quality of care from staff.

Detection bias

Blinding outcome assessors to treatment groups is difficult for this type of intervention, and we rated 53 of 63 trials with subjective outcomes at high risk of detection bias. In nine trials, outcome assessors were blind to group assignment and observed maternal‐infant behavior after the conclusion of the intervention. We rated these trials at unclear risk of bias. In Svejda 1980, outcome data were derived from observations of videotapes of maternal behavior coded by researchers who were described as being blind to group assignment (low risk of bias).

Blinding (performance bias and detection bias): objective outcomes

Performance bias

Objective outcomes (e.g. maternal blood loss, plasma hemoglobin, and placental separation time; infant axillary temperature, blood glucose, and SCRIP score) are unlikely to be influenced by mother or staff awareness of group assignment. We rated all 45 trials with objective outcomes at low risk of performance bias for these outcomes.

Detection bias

Objective outcomes such as maternal plasma hemoglobin or infant blood glucose are unlikely to be influenced by outcome assessor awareness of group assignment. We considered 12 of the 45 trials with objective outcomes at low risk of detection bias because the assessor was blind to group assignment or obtained data for one of these outcomes. However, awareness of group assignment could influence how assessors measure certain objective outcomes, such as infant axillary temperature, infant SCRIP score, maternal blood loss, or placental separation time. For studies in which an unblinded assessor obtained one of these outcomes, we rated the risk of detection bias as unclear.

Incomplete outcome data (attrition bias)

We considered five trials at high risk of attrition bias due to missing data at specific time points or unclear denominators (Aydin 2022; Crenshaw 2019; Kollmann 2017; Vaidya 2005; Villalon 1992 [117, 118]). There was clear reporting on all participants in 46 trials (low risk of bias). We rated the remaining 18 trials at unclear risk of attrition bias because denominators were unclear or not reported, or because we were unsure of the impact of incomplete or unclear follow‐up at specific time points.

Selective reporting (reporting bias)

To evaluate selective reporting, we reviewed the outcomes listed in the methods section of the individual trials or in a trial protocol, if available, and then examined whether data for these outcomes were reported in the results section.

We judged 51 trials at low risk of reporting bias because they reported all prespecified outcomes. The impact of selective reporting was unclear in 15 trials. Issues included reporting of insignificant differences between groups with no numerical data, outcomes only measured in the intervention group, results not reported according to randomization group, or multiple observation points. In three trials, there was no systematic reporting of longer‐term outcomes collected at three months, six months, nine months, and 12 months, so we rated them at high risk of reporting bias (Sosa 1976a [119]; Sosa 1976b [120]; Sosa 1976c [121]).

Other potential sources of bias

In 27 trials, there were no baseline between‐group differences in social, demographic, or medical characteristics or co‐interventions that could influence outcomes, so we rated them at low risk of bias in this domain. We identified possible differences in baseline characteristics between arms or discrepancies in the published reports of 35 trials, which we rated at unclear risk.

Seven trials had factors that we felt deserved a high risk of 'other bias' judgment. The infants in both arms of Gouchon 2010 were bathed before returning to their mother, which would impact the temperature outcome. Bergman 2004 had difficulty recruiting women and stopped the trial after interim analyses favored the intervention. In Marin 2010, SSC infants weighed less than controls, and the trial report provided no details of adjustments made for cluster‐design (randomization of pediatricians rather than women). Infants receiving the intervention in Nolan 2009 had significantly higher cortisol and weighed more than control infants; further, this trial had several co‐interventions. More women in the control group of Sosa 1976a had poor socioeconomic status as measured with a socioeconomic index score; the study authors used this to explain the difference in breastfeeding status favoring the control group. Syfrett 1993 included few participants—recruited at times convenient to the investigators—and multiple co‐interventions. Gregson 2016 compared immediate SSC in the operating room to standard SSC occurring after completion of cesarean birth. The authors documented some "contamination" in the control group, indicating that these mothers had a longer duration of SSC than the researchers originally intended.

Synthesis of results

Comparison 1. Immediate or early skin‐to‐skin contact versus standard contact for healthy infants and their mothers

Critical outcomes

Breastfeeding/lactation

Exclusive breastfeeding at hospital discharge to one month postbirth

SSC probably increases rates of exclusive breastfeeding at hospital discharge (RR 1.36, 95% CI 1.19 to 1.56; I² = 62%; 12 studies, 1556 mother‐infant pairs, moderate‐certainty evidence; Analysis 1.1).

We conducted a sensitivity analysis to investigate the effects of the cluster design in Marin 2010 by excluding this trial (RR 1.40, 95% CI 1.19 to 1.64; I² = 64%; 11 studies, 1318 mother‐infant pairs; Analysis 1.2).

There was moderate heterogeneity due to the inclusion of Perez‐Jimenez 2023, which was an outlier. A sensitivity analysis excluding this trial reduced the heterogeneity (RR 1.29, 95% CI 1.20 to 1.39; I² = 0%; 11 studies, 1476 mother‐infant pairs; Analysis 1.3).

Exclusive breastfeeding at six weeks to six months postbirth

SSC probably increases rates of exclusive breastfeeding 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; Analysis 1.4). There was considerable heterogeneity for this outcome, so the results should be interpreted with caution. However, removing Mulupuru 2019 in a sensitivity analysis reduced heterogeneity without affecting the point estimate (RR 1.38, 95% CI 1.19 to 1.61; I² = 43%; 10 studies, 943 mother‐infant pairs; Analysis 1.5). In this study, exclusive breastfeeding rates were very high in both groups (94.8% in the SSC group and 95.7% in the control group), so there may have been a ceiling effect.

Infant physiological stability

Infant axillary temperature at 30 minutes to 2.5 hours postbirth

SSC probably results in a slight increase in infant axillary temperature (measured in ° C) at 30 minutes to 2.5 hours postbirth (MD 0.28, 95% CI 0.14 to 0.41; I² = 95%; 11 studies, 1349 infants; moderate‐certainty evidence; Analysis 1.6). However, an MD of 0.28 °C does not represent a clinically meaningful difference. All infants except those in Bystrova 2003 [122, 123, 124, 125, 126, 127] had a temperature between 36 °C and 37.1 °C. Results from this meta‐analysis should be interpreted with caution due to heterogeneity and some studies with very small sample sizes.

Infant blood glucose level at 75 minutes to 180 minutes postbirth

SSC probably increases infant blood glucose (measured in mg/dL) at 75 minutes to 180 minutes postbirth (MD 10.49, 95% CI 8.39 to 12.59; I² = 0%; 3 studies; 144 infants; moderate‐certainty evidence; Analysis 1.7). A difference of 10 mg/dL in blood glucose levels is clinically significant because symptomatic or high‐risk infants may be given supplemental bottles of infant formula, a practice that can interfere with the establishment of successful breastfeeding.

Infant SCRIP score during the first six hours postbirth

SSC may result in a large increase in SCRIP scores during the first six hours postbirth, suggesting better transition to extrauterine life (SMD 1.24, 95% CI 0.76 to 1.72; I² = 0%; 2 studies; 81 infants; low‐certainty evidence; Analysis 1.8). However, this result is based on only two studies, and no new data have been added since the 2016 review.

Maternal physiology

Placental separation time/duration of the third stage of labor

Placental separation time or duration of the third stage of labor was measured by a stopwatch or chronometer in four studies. SSC may have little to no effect on 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; Analysis 1.9). These findings should be interpreted with caution because of high heterogeneity for this outcome and because the CI included appreciable benefit and harm. When we excluded Gunduz 2023 in a sensitivity analysis, the CI no longer included appreciable harm (MD ‐0.90, 95% CI ‐1.79 to ‐0.02; I² = 0%; 3 studies; 366 mothers; Analysis 1.10).

Maternal blood loss during/after vaginal birth

We were only able to combine the results of two studies for the outcome of maternal blood loss after vaginal birth. The results suggest no clear difference in the amount of blood loss (mL) between the SSC and the control group, but the evidence is very uncertain (MD ‐145.92, 95% CI ‐416.96 to 125.11; I² = 97%; 2 studies; 143 mothers; very low‐certainty evidence; Analysis 1.11). These results should be interpreted with caution because of the high heterogeneity, small number of studies, and wide CI for this outcome, including appreciable benefit and harm.

Aydin 2022 reported a mean intrapartum blood loss of 206.25 mL in the SSC group and 353.57 mL in the control group (P = 0.033), and a mean intrapartum plus postpartum blood loss of 499.71 mL in the SSC group and 933.87 mL in the control group (P = 0.041).

Incidence of postpartum hemorrhage

No studies in this comparison assessed the incidence of postpartum hemorrhage.

Important outcomes

Breastfeeding/lactation

Any breastfeeding at one month to four months postbirth

Our meta‐analysis suggests that more SSC dyads than standard contact dads were still breastfeeding at one month to four months postbirth (RR 1.24, 95% CI 1.07 to 1.43; I² = 41%; 14 studies; 887 mother‐infant pairs; Analysis 1.12). Overall, there were differences in the size of the treatment effect between studies, leading to moderate heterogeneity in this outcome. Much of the heterogeneity was due to a single study where the study author speculated that variation in treatment effect was due to the higher number of women with lower socioeconomic status randomized to the control group (Sosa 1976a). We removed this study in a sensitivity analysis, which reduced statistical heterogeneity and had little impact on the overall treatment effect (RR 1.30, 95% CI 1.17 to 1.46; I² = 0%; 13 studies; 827 mother‐infant pairs; Analysis 1.13). Another two studies with the same lead author reported no influence of socioeconomic status on this outcome (Sosa 1976b; Sosa 1976c).

Duration of any breastfeeding

Our meta‐analysis suggests women randomized to SSC breastfed their infants for longer than women randomized to standard contact, although the 95% CI also includes a slight reduction in duration of any breastfeeding (MD 42.55, 95% CI ‐1.69 to 86.79; I² = 66%; 7 studies; 324 mother‐infant pairs; Analysis 1.14). Much of the heterogeneity was due to Sosa 1976a, where women in the control group breastfed their babies for longer. We excluded this study in a sensitivity analysis, which removed all heterogeneity; the results then favored women with SSC, who breastfed their infants for 64 days longer on average (MD 63.73, 95% CI 37.96 to 89.50; I² = 0%; 6 studies; 264 mother‐infant pairs; Analysis 1.15).

Breastfeeding status/level of breastfeeding exclusivity at one month postbirth

Three studies with 245 women examined breastfeeding status at one month postbirth using the IBS. Our meta‐analysis indicates little to no difference between groups for this outcome (MD 0.86, 95% CI ‐0.73 to 2.44; I² = 90%; 3 studies; 245 mother‐infant pairs; Analysis 1.16). The results varied considerably between studies, so the average treatment effect should be interpreted with caution.

Successful first breastfeeding

The SSC group had higher IBFAT or LATCH scores on average, indicating a higher rate of successful first breastfeeding (SMD 0.79, 95% CI 0.11 to 1.48; I² = 93%; 6 studies; 580 mother‐infant pairs; Analysis 1.17). However, there was marked heterogeneity for this outcome.

Eight studies evaluated successful breastfeeding as a dichotomous outcome, defining success as an IBFAT score of 10 to 12 or a Breastfeeding Assessment Tool (BAT) score of 8 to 12. Our analysis suggests dyads who had SSC were more likely to achieve successful first breastfeeding than the control group, where mothers held their infants swaddled in blankets (RR 1.53, 95% CI 1.17 to 2.01; I² = 90%; 8 studies; 825 mother‐infant pairs; Analysis 1.18). Two studies used no validated scale to measure breastfeeding success but rather stated that this outcome was "observed" by the researchers (Liao 2020; Perez‐Jimenez 2023).

Time from birth to first breastfeeding initiation

Our meta‐analysis of data from two studies suggests the time from birth to initiation of breastfeeding was 48 minutes shorter on average among dyads who had SSC (MD ‐47.76, 95% CI ‐52.77 to ‐42.75; I² = 53%; 2 studies; 204 mother‐infant pairs; Analysis 1.19).

Maternal breastfeeding confidence

In Karimi 2014, mothers in the SSC group reported more breastfeeding confidence, with a mean Breastfeeding Self‐efficacy Scale score of 53.42, compared with 49.85 in the control group.

Infant physiological stability

Transfer to the neonatal intensive care unit

Our meta‐analysis indicates no clear differences between the SSC and standard contact group in the rate of infant transfer to the NICU (RR 0.73, 95% CI 0.22 to 2.48; I² = 55%; 4 studies; 833 infants; Analysis 1.20). We excluded Marin 2010 in a sensitivity analysis to investigate the effects of the cluster design (RR 1.08, 95% CI 0.16 to 7.40; I² = 66%; 3 studies; 559 infants; Analysis 1.21).

Infant bodyweight change/rate of growth

Two studies measured change in infant bodyweight (g) at 14 days postbirth (Chwo 1999; Moore 2005 [128, 129, 130]). Our meta‐analysis indicates no clear difference between the groups (MD ‐8.00, 95% CI ‐175.60 to 159.61; I² = 0%; 2 studies; 43 infants; Analysis 1.22). No studies have reported the rate of infant growth. Recent trials reported infant weight outcomes in several ways, but we were unable to add these data to our prespecified analyses.

Girish 2013 reported infant weight loss at three days postpartum (mean 18 g [SD 6] in the SSC group and mean 23 g [SD 9] in the control group). Thukral 2012 reported infant weight at 48 hours (mean 2714 g [SD 220] in the SSC group [n = 20] and mean 2574 g [SD 275] in the control group [n = 21]; P = 0.11). Srivastava 2014 [131] reported weight loss at hospital discharge as a percentage of birthweight (mean 4.01% [SD 2.0] in the SSC group [n = 122] and mean 6.12% [SD 2.6] in the control group [n = 118]).

Maternal physiology, attitudes, maternal‐infant bonding/attachment

Maternal pain during episiotomy or perineal laceration repair and up to two hours after

Five studies measured maternal pain during the two hours after episiotomy or perineal laceration repair using a Likert scale of 0 to 10, with 10 indicating the worst pain imaginable. Mothers in the SSC group reported less pain than those in the control group on average (MD ‐0.58, 95% CI ‐1.02 to ‐0.15; I² = 72%; 5 studies; 761 mothers; Analysis 1.23), but there was substantial heterogeneity for this outcome. Taechavichitpisal 2023 reported a median pain after episiotomy score of 1.99 in the SSC group and 3.4 in the control group (P < 0.001).

Maternal plasma hemoglobin at two days to three days postbirth

No studies in this comparison reported maternal plasma hemoglobin at two days to three days postbirth.

Maternal salivary cortisol during skin‐to skin or standard contact and up to one day postbirth

No studies in this comparison reported maternal salivary cortisol during SSC or standard contact or up to one day postbirth.

Maternal anxiety at two hours to three days postbirth

On average, mothers who had SSC displayed less anxiety measured on the state anxiety scale at three days postbirth, though we are unsure of the clinical meaning of this difference (SMD ‐0.50, 95% CI ‐0.87 to ‐0.13; I² = 70%; 4 studies; 490 mothers; Analysis 1.24). As a rule of thumb, an SMD of 0.50 represents a moderate effect [132].

Maternal perceptions of bonding with her infant and sensitivity to her infant's cues at 12 months postbirth

Bystrova 2003 used the PCERA to evaluate perceptions of bonding in 61 mothers. The PCERA has eight subscales evaluating maternal and infant behavior and interaction [29, 30]. Bystrova 2003 found no evidence of group differences for maternal positive affective involvement at 12 months postbirth (MD 1.90, 95% CI ‐1.14 to 4.94; 1 study, 61 mothers). However, SSC dyads appeared more mutual and reciprocal (MD 1.30, 95% CI 0.24 to 2.36; 1 study, 61 mothers) than those who were separated immediately after birth and later reunited for rooming‐in. We do not consider the MD for mutuality and reciprocity to be clinically significant; the difference of 1.30 units is less than 10% of the overall possible score.

Mother's preference for the same postdelivery care in the future

On average, mothers who had SSC indicated a strong preference for the same type of postdelivery care in the future compared to those who held their infants swaddled (RR 6.04, 95% CI 2.05 to 17.83; I² = 85%; 3 studies; 439 mothers; Analysis 1.25). However, there was high heterogeneity for this outcome.

Comparison 2. Immediate or early skin‐to‐skin contact versus standard contact for healthy infants and their mothers after cesarean birth

Thirteen trials compared SSC to standard contact after a cesarean birth. Five trials began SSC in the operating room immediately after birth (Armbrust 2016; Kollmann 2017; Yuksel 2016; Zafran 2019; Zhang 2023). Five trials began SSC in the recovery room (Beiranvand 2014; Gouchon 2010; McClellan 1980; Nasehi 2012; Nolan 2009). Perez‐Jimenez 2023 and Pouraboli 2019 began early SSC in the operating room after the infant was assessed by the pediatrician. There was no information in Norouzi 2013 about when SSC was initiated. The women in 12 trials received regional anesthesia (epidural or spinal), while those in Nasehi 2012 received general anesthesia. All the mothers had primary or repeat elective cesarean births. No studies included women who had an emergency cesarean. All infants were full term.

Critical outcomes

Breastfeeding/lactation

Exclusive breastfeeding at hospital discharge to one month postbirth

Our meta‐analysis suggests that exclusive breastfeeding was more common among the dyads with SSC at hospital discharge to one month after cesarean birth (RR 1.50, 95% CI 1.02 to 2.21; I² = 80%; 5 studies; 722 mother‐infant pairs; Analysis 2.1), although there was high heterogeneity for this outcome.

Exclusive breastfeeding at six weeks to six months postbirth

Our meta‐analysis suggests little to no difference between the two groups in rates of exclusive breastfeeding at six weeks to six months after cesarean birth, though data were limited (RR 1.16, 95% CI 0.95 to 1.43; I² = 0%; 2 studies; 144 mother‐infant pairs; Analysis 2.2).

Infant physiological stability

No study in this comparison assessed infant axillary temperature, blood glucose levels, or SCRIP score.

Maternal physiology

Placental separation time/duration of the third stage of labor

No studies in this comparison assessed placental separation time.

Maternal blood loss during/after cesarean birth

Zhang 2023 reported a median intraoperative blood loss of 300 mL in the SSC group and 350 mL in the control group (P = 0.102), measured by the volume of fluids in drains and reported as a median because the data were skewed. Zhang 2023 also reported the median postoperative blood loss measured by weighing all "used materials", which was 108 mL in the SSC group and 400 mL in the control group (P < 0.001).

Incidence of postpartum hemorrhage

Only Zafran 2019 reported the incidence of postpartum hemorrhage (defined as 1000 mL blood loss and estimated by the surgeon) after cesarean birth. Five of 102 mothers in the SSC group and seven of 89 in the control group had postpartum hemorrhage (P = 0.4).

Breastfeeding/lactation

Any breastfeeding at one month to four months postbirth

Our meta‐analysis of data from two small trials suggests that women who had SSC were more likely on average to be breastfeeding at one month to four months after cesarean birth (RR 1.22, 95% CI 1.04 to 1.44; I² = 0%; 2 studies; 220 mother‐infant pairs; Analysis 2.3).

Duration of any breastfeeding

No studies in this comparison reported duration of any breastfeeding.

Breastfeeding status/level of breastfeeding exclusivity at one month postbirth

No studies in this comparison reported breastfeeding status/level of breastfeeding exclusivity at one month postbirth.

Successful first breastfeeding

Our meta‐analysis indicates a small difference in favor of SSC in successful first breastfeeding according to the IBFAT score (MD 1.37, 95% CI 0.12 to 2.62; I² = 0%; 2 studies; 124 mother‐infant pairs; Analysis 2.4). The score ranges from 0 to 12, so an MD of 1.37 represents an 11.4% increase.

Time from birth to first breastfeeding initiation

No studies in this comparison reported time from birth to first breastfeeding initiation.

Maternal breastfeeding confidence.

No studies in this comparison reported maternal breastfeeding confidence.

Infant physiological stability

Transfer to the neonatal intensive care unit

Our meta‐analysis indicates little to no between‐group difference in NICU admissions (RR 1.02, 95% CI 0.05 to 21.47; I² = 82%; 2 studies; 528 infants; Analysis 2.5).

Infant bodyweight change/rate of growth

No studies in this comparison reported infant bodyweight change or rate of growth

Maternal physiology

Maternal pain after cesarean birth

Our meta‐analysis indicates little to no between‐group difference in pain (measured on a 0–10 scale, with 10 indicating the worst pain imaginable) after cesarean birth on arrival to recovery to four hours postoperatively, although the CIs were wide and included appreciable benefit and harm (MD ‐3.11, 95% CI ‐6.41 to 0.19; I² = 93%; 2 studies; 115 mothers; Analysis 2.6).

Yuksel 2016 reported maternal pain 48 hours postoperatively. The SSC group had a mean score of 5.3 and the control group 5.7.

Maternal plasma hemoglobin at two days to three days postbirth

Our meta‐analysis indicates little to no difference between mothers who had SSC versus standard contact in plasma hemoglobin levels (g/dL) at two days to three days postbirth (MD 0.16, 95% CI ‐0.58 to 0.89; I² = 83%; 2 studies; 271 mothers; Analysis 2.7).

Zhang 2023 reported no difference in median plasma hemoglobin levels 90 minutes postoperatively (113 g/L in the SSC group and 116 g/L in the control group).

Maternal salivary cortisol during skin‐to‐skin or standard contact and up to one day postbirth

Kollmann 2017 found no between‐group differences in maternal salivary cortisol levels 25 minutes postoperatively (median 13.2 ng/mL in SSC group and median 12.04 ng/mL in control group).

Maternal anxiety at two hours to three days postbirth

No studies in this comparison reported maternal anxiety.

Maternal perceptions of bonding with her infant and sensitivity to her infant's cues at 12 months postbirth

No studies in this comparison reported maternal perception of bonding.

Mother's preference for the same postdelivery care in the future

No studies in this comparison reported mothers' preference for the same postdelivery care in the future.

Comparison 3. Immediate or early skin‐to‐skin contact versus standard contact by timing of skin‐to‐skin contact initiation (subgroup analysis)

For this subgroup analysis, we evaluated differences between SSC and standard contact in trials that initiated SSC less than 10 minutes postbirth (immediate SSC) and in trials that initiated SSC from 10 minutes postbirth (early SSC).

There was no evidence of subgroup differences by time of initiation of SSC in exclusive breastfeeding at hospital discharge to one month postbirth (Analysis 3.1), exclusive breastfeeding at six weeks to six months postbirth (Analysis 3.2), any breastfeeding at one month to four months postbirth (Analysis 3.3), duration of any breastfeeding (Analysis 3.4), and infant axillary temperature at 30 minutes to 2.5 hours postbirth (Analysis 3.5).

Comparison 4. Immediate or early skin‐to‐skin contact versus standard contact by duration of skin‐to‐skin contact (subgroup analysis)

For this subgroup analysis, we evaluated differences between SSC and standard contact in trials that evaluated 60 minutes or less of SSC (low dose) and in trials that evaluated more than 60 minutes of SSC (high dose).

There was no evidence of subgroup differences by duration of SSC for exclusive breastfeeding at hospital discharge to one month postbirth (Analysis 4.1), exclusive breastfeeding at six weeks to six months postbirth (Analysis 4.2), any breastfeeding at one month to four months postbirth (Analysis 4.3), and duration of any breastfeeding (Analysis 4.4).

However, our subgroup analysis suggests that the difference in axillary temperature between SSC and standard contact was smaller in the trials with a low dose of SSC (MD 0.09, 95% CI ‐0.05 to 0.23; I² = 82%; 3 studies, 599 infants; Analysis 4.5.1) versus trials with a high dose (MD 0.36, 95% CI 0.19 to 0.52; I² = 89%; 8 studies, 750 infants; Analysis 4.5.2). The test for subgroup differences gave a P value of 0.02 and an I² value of 82.7%. The observed differences in infant temperature are not clinically important.

Comparison 5. Immediate versus early skin‐to‐skin contact for healthy infants and their mothers

Four trials compared SSC beginning immediately after birth with SSC beginning 10 minutes to 24 hours after birth (Agudelo 2021; Crenshaw 2019; Gregson 2016; Walsh 2021). These studies measured three of our critical outcomes (exclusive breastfeeding at hospital discharge to one month postbirth, exclusive breastfeeding at six weeks to six months postbirth, infant blood glucose levels) and two of our important outcomes (transfer to the NICU, maternal salivary cortisol).

Our meta‐analyses indicate little to no difference between immediate SSC and early SSC in rates of exclusive breastfeeding at hospital discharge to one month postbirth (RR 1.02, 95% CI 0.95 to 1.09; I² = 11%; 3 studies; 697 mother‐infant pairs; Analysis 5.1), exclusive breastfeeding at six weeks to six months postbirth (RR 1.12, 95% CI 0.93 to 1.35; I² = 0%; 2 studies; 644 mother‐infant pairs; Analysis 5.2), or infant transfer to the NICU (RR 1.39, 95% CI 0.52 to 3.72; I² = 38%; 2 studies; 416 infants; Analysis 5.3).

Crenshaw 2019 found that mothers who had immediate SSC had lower salivary cortisol levels two hours after admission to the mother‐baby unit compared with mothers who had early SSC (P = 0.017). Walsh 2021 found no difference in infant blood glucose levels between the immediate and early SSC groups (P = 0.77).

Lack of data limits any conclusions we can make about the importance of SSC timing.

Comparison 6. High‐dose (more than 60 minutes) versus low‐dose (up to 60 minutes) skin‐to‐skin contact for healthy infants and their mothers

Only two trials directly compared a high to a low dose of SSC (Raj Kumawat 2024; Zhang 2023). They measured three of our critical outcomes (exclusive breastfeeding at hospital discharge to one month postbirth, exclusive breastfeeding at six weeks to six months postbirth, maternal blood loss during/after vaginal or cesarean delivery) and two of our important outcomes (infant transfer to the NICU, maternal plasma hemoglobin).

Our meta‐analysis indicates little to no difference between high‐dose SSC and low‐dose SSC in rates of exclusive breastfeeding at hospital discharge to one month postbirth (RR 1.21, 95% CI 0.86 to 1.68; I² = 85%; 2 studies; 538 mother‐infant pairs; Analysis 6.1). Raj Kumawat 2024 found that exclusive breastfeeding at 10 weeks postbirth was more common in the high‐dose group (P = 0.01). Zhang 2023 found lower maternal postoperative blood loss in the high‐dose group (P < 0.001), but no group differences for intraoperative blood loss (P = 0.102) or maternal plasma hemoglobin before discharge after a cesarean birth (P = 0.256).

Zhang 2023 also reported that 1/176 infants in the low‐dose group and 2/164 infants in the high‐dose group were transferred to the NICU (P = 0.022).

Lack of data limits any conclusions we can make about the importance of SSC duration.

Equity assessment

We divided the included studies by World Bank country income classification in a subgroup analysis (Comparison 7). No trials were conducted in low‐income countries, so we compared lower‐middle‐income countries with upper‐middle‐ and high‐income countries. We found no subgroup differences for exclusive breastfeeding at hospital discharge to one month postbirth (Analysis 7.1), exclusive breastfeeding at six weeks to six months postbirth (Analysis 7.2), or infant axillary temperature at 30 minutes to 2.5 hours postbirth (Analysis 7.3). These results suggest that SSC compared to standard contact is equally effective for improving these outcomes in lower‐middle‐income countries compared with upper‐middle‐ to high‐income countries, although SSC is underutilized in low‐income‐ and lower‐middle‐income countries [2].

Reporting biases

We generated four funnel plots and found no evidence of asymmetry (Figure 4; Figure 5; Figure 6; Figure 7).

4.

Funnel plot of comparison: 1 Skin‐to‐skin versus standard contact for healthy infants, outcome: 1.1 Breastfeeding 1 month to 4 months post birth.

Footnotes
RR: risk ratio; SE(log[RR]): standard error of the natural logarithm of the risk ratio

5.

Funnel plot of comparison: 1 Immediate or early skin‐to‐skin contact versus standard contact for healthy infants, Outcome: 1.1 Number of mothers exclusively breastfeeding at hospital discharge to 1 month postbirth.

Footnotes
RR: risk ratio; SE(log[RR]): standard error of the natural logarithm of the risk ratio

6.

Funnel plot of comparison: 1 Immediate or early skin‐to‐skin contact versus standard contact for healthy infants, Outcome: 1.2 Number of mothers exclusively breastfeeding 6 weeks to 6 months postbirth.

Footnotes
RR: risk ratio; SE(log[RR]): standard error of the natural logarithm of the risk ratio

7.

Funnel plot of comparison: 1 Immediate or early skin‐to‐skin contact versus standard contact for healthy infants, Outcome: 1.3 Infant axillary temperature 30 minutes to 2.5 hours postbirth.

Footnotes
MD: mean difference; SE(MD): standard error (mean difference)

Discussion

Summary of main results

This review summarizes the results of 69 trials (7290 mother‐infant pairs) that met our inclusion criteria. Most studies (43) compared immediate SSC with standard hospital care. Twelve trials were conducted in low‐middle‐income countries, 25 in upper‐middle‐income countries, and 32 in high‐income countries. Ten studies recruited late preterm infants and 15 recruited women who had a cesarean birth. Four trials compared immediate SSC (initiated < 10 minutes postbirth) with early SSC (initiated ≥ 10 minutes postbirth), and two trials compared high‐dose SSC (> 60 minutes) with low‐dose SSC (< 60 minutes). Risk of bias assessments for the included studies can be found in Figure 2, Figure 3, and the Risk of bias in included studies section.

Mothers who have SSC are probably 36% more likely to be exclusively breastfeeding at hospital discharge to one month postbirth (12 trials, 1556 mother‐infant pairs) and 38% more likely to be exclusively breastfeeding at six weeks to six months postbirth (11 trials, 1135 mother‐infant pairs). These findings of improved breastfeeding were similar in lower‐middle‐income countries and upper‐middle‐ to high‐income countries. We consider these results to be clinically significant.

The included studies relating to consumer experience with SSC reflect that SSC is a positive experience for families, and mothers would choose SSC for future births (Carfoot 2004 [133]; Mahmood 2011 [134]; Nahidi 2011 [135]).

We considered the mean infant axillary temperature difference of 0.28 °C favoring the SSC group (11 trials, 1349 infants) was not clinically meaningful, but clinicians can be assured that infants who receive SSC are not at greater risk for hypothermia.

Infants who experience SSC with their mothers probably have higher blood glucose levels (MD 10.49 mg/dL higher; 3 trials, 144 infants) than those who have standard contact. An arbitrary cutoff for treatment of symptomatic newborns is 40 mg/dL [136], and the goal is to maintain plasma glucose levels between 40 mg/dL and 50 mg/dL [136, 137]. We consider the between‐group difference of 10 mg/dL to be clinically significant because symptomatic or high‐risk infants may be given supplemental bottles of infant formula, and this practice can interfere with the establishment of breastfeeding.

The SCRIP score is a composite measure of transition to extrauterine life through a timeline describing cardiorespiratory stabilization at repeated time points in the first hours after birth. Cardiac and respiratory parameters assessed at a single time point cannot adequately measure stabilization. Infants who have SSC may have higher SCRIP scores (SMD 1.24 higher; 2 trials, 81 infants), indicating better stabilization after birth. These studies included only the more vulnerable population of late preterm infants; we can only speculate that the effects would be similar in the full‐term population.

SSC may result in little to no difference in placental separation time/duration of the third stage of labor (MD 2.26 minutes less; 4 trials, 450 mothers). There is no consensus on a timeframe for the delivery of the placenta. If a woman is bleeding moderately, expediting the delivery of the placenta is extremely important. If there is no bleeding, the significance is less. In hospitals with strict protocols where the placenta must be delivered within a certain time frame to avoid interventions, a 2.26‐minute difference could be considered significant and would affect the medical interventions.

There was no clear between‐group difference in maternal blood loss after vaginal births (2 trials, 143 mothers), but the results should be interpreted with caution due to the high heterogeneity of the data and the small number of included studies. Postpartum hemorrhage is a critical outcome for childbirth. Experts hypothesize that the risk of postpartum hemorrhage is influenced by many complex factors, including maternal and exogenous oxytocin amounts, the movement of the newborn's feet massaging the uterus during SSC, active management of the third stage of labor, timing of the placental expulsion, breastfeeding within the first hour of birth, and amount of blood loss. A deeper understanding of these complexities is needed to understand the role of SSC in possibly decreasing postpartum hemorrhage [138].

Limitations of the evidence included in the review

We considered the evidence for the two dichotomous exclusive breastfeeding outcomes to be of moderate certainty, which means we are moderately confident that our results approach the true impact of SSC. We downgraded once for risk of bias concerns, mainly related to lack of blinding, attrition, and unclear reporting of allocation. Detailed footnotes in Table 1 explain our decisions for seven critical outcomes.

Most included studies did not define exclusive breastfeeding or success at first breastfeeding, or the definition was unclear (see Supplementary material 10). In some studies, breastfeeding was considered a dichotomous variable (yes/no). No studies defined progression to the breast by the newborn during SSC and self‐attachment as a breastfeeding outcome, or considered it indicative of success at first feeding, although WHO/UNICEF Baby‐Friendly Hospital Initiative guidelines recommend this approach [1]. Instead, studies used breastfeeding assessment tools (IBFAT and LATCH), which have not been shown to be reliable [26]. There were numerous gaps in the reporting of the infant's breastfeeding behavior (see Supplementary material 11). Further, the timing and duration of SSC were highly variable, and in some cases very short or delayed. Another possible source of bias was additional interventions, such as breastfeeding guidance by healthcare providers, making it difficult to disentangle the effect of SSC from the other interventions. Nonetheless, the pooled findings are based on many observations and consistently show moderate effects in favor of SSC.

Sufficient research has shown that SSC newborns are not colder than their separated counterparts, even when the separated babies are under radiant warmers. Most studies assessed infant temperature in the axilla. Studies did not consistently report factors that may influence infant temperature, including maternal and ambient temperature. For this outcome, we downgraded the certainty of the evidence to moderate for inconsistency, due to one trial finding a higher axillary temperature in the control group.

We considered the certainty of the evidence for infant blood glucose levels to be moderate because of imprecision related to small sample size.

We considered the results for SCRIP scores to be of low certainty, which means future good‐quality studies may change the effect estimates presented in this review. We downgraded once for risk of bias and once for imprecision, as data were very limited (two trials, 81 infants), and it is possible that trialists' averaging of scores over several time points led to an exaggerated SMD.

Four studies measured mean time for placental separation (separation from the uterus but still within the vagina) or expulsion (complete delivery of the placenta) with stopwatches, although not all studies reported their methodology clearly. There were inconsistencies in the definition of expulsion or separation, along with a lack of reporting about possible confounding factors including the length of labor, previous uterine surgeries, uterine infection rate, and clinician actions during the third stage of labor (e.g. active management of the placenta, administration of oxytocin or other medications). The time of the cord clamping was unreported or inconsistent. All these factors could impact the timing of placental expulsion (see Supplementary material 12). The certainty of evidence for placental separation time/length for the third stage of labor was low (4 trials, 450 participants) due to inconsistency and imprecision. We did not downgrade for risk of bias, although all trials were rated at unclear risk of bias for blinding of outcome assessment (objective outcome), and three of the four for allocation concealment.

Although our meta‐analysis showed no between‐group differences in maternal blood loss after vaginal birth, the results should be interpreted with caution due to very limited data (2 studies; 143 participants), inconsistency, imprecision, and high risk of attrition bias in one trial. We rated the certainty of the evidence as very low. The investigators collected data on both intrapartum and postpartum blood loss, used different methods for determining the amount, had different start and end times, often did not provide a definition of postpartum hemorrhage, and did not list relevant comorbidities for mothers (see Supplementary material 13). Postpartum hemorrhage could be 500 mL or more than 1000 mL of blood loss. It could be symptomatic or asymptomatic. It could be within two hours, 24 hours, or 12 days of birth. Measurements of postpartum hemorrhage could involve hemoglobin tests (comparing before and after delivery, or only collected after), estimation of blood loss, or weighing of pads, making conclusions difficult. Visual estimation can be inaccurate, and pads and collection devices can be prohibitively expensive. The understanding of blood loss volume is complicated by additional substances that could be mixed with the blood (such as amniotic fluid, urine, stool, meconium), as well as the reason for the blood loss (such as uterine atrophy, cervical damage, episiotomy). These studies provided no description of other interventions used to prevent postpartum hemorrhage (e.g. oxytocin, active management of the third stage of labor) for mothers in either group. These factors decrease our confidence in the results related to blood loss and postpartum hemorrhage.

We found no eligible RCTs conducted in low‐income countries, which may limit the generalizability of our findings.

The studies reported few adverse events. In Gregson 2016, two full‐term babies collapsed unexpectedly while in SSC. One rare but potentially catastrophic adverse event is sudden unexpected postnatal collapse (SUPC). SUPC appears in apparently healthy newborns (> 35 weeks' gestation) during the first seven days of life but is often preventable. Therefore, in clinical practice, safety concerns related to SSC need to be considered. Supplementary material 14 provides a more thorough description of safety concerns, including symptoms and clinician actions to prevent SUPC occurrence. Future studies should report adverse events that relate to SSC safety concerns.

Limitations of the review processes

We are aware that the review process may be affected by bias, and we attempted to minimize this risk in several ways. Our search for eligible trials was comprehensive (Supplementary material 1). At least two review authors independently assessed study eligibility, carried out data extraction, and assessed the risk of bias. However, some aspects of the review process involve subjective judgments: assessing the risk of bias in included studies, for example, is not an exact science, and a different review team could have reached different conclusions. We justified our decisions in the risk of bias tables. We also recorded details about the participants and interventions in individual studies, and we would encourage readers to interpret results in light of the information set out in Supplementary material 2. Two review authors were involved in included trials. These trials were assessed for inclusion and methodological quality by different review authors.

We conducted our searches of electronic databases from 17 December 2015 to 22 March 2024, more than one year before the publication of this update. However, we searched two trial registers in July 2025 and found only two ongoing trials (NCT06514352 and NCT06011096). We also conducted an informal search of MEDLINE, Embase and CINAHL from 22 March 2024 to 30 June 2025 and found only one potentially eligible trial, which we listed as awaiting classification (Xu 2024 [139]). It is unlikely that the inclusion of Xu 2024 would affect the conclusions of our review, and the two ongoing studies have no published results.

Agreements and disagreements with other studies or reviews

Our findings are generally consistent with those of previous systematic reviews on this topic.

In their recent systematic review and meta‐analysis of 13 quasi‐randomized studies and RCTs with 1369 participants, Lord and colleagues evaluated the effect of SSC compared with standard contact on exclusive breastfeeding from hospital discharge to three months postbirth and obtained results similar to those in our review (RR 1.38, 95% CI 1.21 to 1.57; I² = 52%). They also found similar results for blood glucose concentration in a meta‐analysis of six RCTs including 428 term, preterm, and low birthweight infants (MD 0.49 mmol/L [8.82 mg/dL], 95% CI 0.30 to 0.67 mmol/L; I² = 0%) [5].

Ramaswamy and colleagues evaluated the effects of SSC compared to no SSC on infant axillary, rectal, or forehead temperature in a meta‐analysis of eight RCTs with 1048 infants. Their results for axillary temperature were similar to ours (MD 0.32 °C, 95% CI 0.10 to 0.54; I² = 95%) [7]. However, in a meta‐analysis of four studies (1 RCT and 3 quasi‐experimental studies, 276 infants) comparing the effects of SSC to usual care, Durmaz and colleagues found a larger difference in mean body temperature favoring the SSC group (SMD 1.040, 95% CI 0.414 to 1.665; I² = 51.478%) [3].

In their systematic review and meta‐analysis of six RCTs and quasi‐randomized trials with 498 mothers, Karimi and colleagues compared the effect of SSC versus routine care on the duration of the third stage of labor. Their results were comparable to ours (MD ‐1.33 minutes, 95% CI ‐2.31 to ‐0.36; I² = 96.6%) [4].

One large hospital‐based cohort study (n = 21,842) demonstrated a clear dose‐response effect of SSC on exclusive breastfeeding at hospital discharge [140]. The study evaluated four levels of SSC. Compared with no SSC, a one‐ to 15‐minute dose was associated with a 1.376 odds ratio (OR) of exclusive breastfeeding during hospitalization, a 16‐ to 30‐minute dose with an OR of 1.665, a 31‐ to 59‐minute dose with an OR of 2.357, and a greater than one‐hour dose with an OR of 3.145. The data in our review were inadequate to demonstrate a dose‐response effect. We were only able to compare a low dose (≤ 60 minutes) with a high dose (> 60 minutes).

Authors' conclusions

Implications for practice

The first hours after birth are a critical period for newborns, where they undergo essential physiological transitions to adapt to extrauterine life. This review supports the guidelines of the United Nations Children's Fund (UNICEF) and the World Health Organization (WHO) to recommend and support skin‐to‐skin contact after birth, including after cesarean birth [1].

Almost all the studies began skin‐to‐skin contact within the first hour postbirth, with most starting within the first 10 minutes of life. Most studies (43) compared immediate skin‐to‐skin contact with standard hospital care, 22 compared early skin‐to‐skin contact with standard hospital care, and four compared immediate skin‐to‐skin contact with early skin‐to‐skin contact. This may represent a trend towards the WHO/UNICEF recommendation of immediate skin‐to‐skin contact, which was published since our last review update. Of note, results were similarly beneficial after a vaginal or cesarean birth. Skin‐to‐skin contact after elective and emergency cesarean birth may be challenging to implement. The complication of needing to maintain a sterile field, the temperature (cold) of the operating theater, and other factors have been noted as reasons for difficulty in implementing skin‐to‐skin contact after cesarean births. However, it is feasible and recommended in the WHO/UNICEF Baby‐Friendly Hospital Initiative guidelines.

Immediate or early skin‐to‐skin contact probably increases exclusive breastfeeding. These findings are of high clinical relevance due to the well‐known health benefits of breastfeeding for infants and mothers. This review does not address subsequent ongoing skin‐to‐skin contact as an intervention to support breastfeeding. However, it is noteworthy that an intervention practiced even for a short time at birth can have measurable effects on exclusive breastfeeding up to six months later.

Immediate or early skin‐to‐skin contact probably increases infant blood glucose, and these results are clinically meaningful. The assessment of blood glucose levels in term infants is controversial. Recent guidelines recommend against screening of healthy newborns unless there are risk factors or clinical symptoms of hypoglycemia present [136, 137]. Neonatal hypoglycemia guidelines recommend that early skin‐to‐skin contact be added as a glucose‐stabilizing strategy for when the newborn makes the transition from a continuous intrauterine glucose supply to intermittent milk feeding.

Newborns probably maintain a normal body temperature while in skin‐to‐skin contact, as there was not a clinically meaningful difference between groups, although infant axillary temperatures were slightly higher in the skin‐to‐skin contact group. Cardiorespiratory stabilization may improve in late preterm infants with skin‐to‐skin contact. However, there is a need to educate healthcare professionals and parents about the safe implementation of skin‐to‐skin contact after birth, such as correct positioning of the newborn on the mother's chest and maintaining an open airway.

Clinical outcomes of skin‐to‐skin contact on maternal physiology are included for the first time in this review. More research is needed to clarify the clinical implications. Skin‐to‐skin contact may result in little to no difference in placental separation time/length of the third stage of labor or in postpartum blood loss. The trials reported no adverse effects for mothers, and there may be potential advantages for mothers in relation to decreased episiotomy pain.

Equity‐related implications for practice

The equity assessment of skin‐to‐skin contact and exclusive breastfeeding that we performed for this review showed that skin‐to‐skin contact is equally effective in promoting exclusive breastfeeding in lower‐middle‐income and in upper‐middle‐ to high‐income countries throughout the world. No included studies were conducted in low‐income countries. Although resources are needed for training, the cost of skin‐to‐skin contact is minimal. No technological equipment, access to electricity, or medications are needed. Skin‐to‐skin contact does not change the need for adequate staffing. This implies that the incremental cost is small relative to the net benefits. Stakeholders include infants, parents, hospital staff, the community, the nation, and the world. Skin‐to‐skin contact is feasible to implement in settings worldwide.

Implications for research

Considering the probable advantages of skin‐to‐skin contact within the first hour postbirth, further research is unlikely to change our conclusions, especially regarding exclusive breastfeeding, duration of any breastfeeding, and infant temperature. More research needs to be conducted on skin‐to‐skin contact after cesarean birth, including the effects of anesthesia, and on very and moderately preterm infants. Only one study included in our review evaluated maternal hospital infections after cesarean birth (Zafran 2019). There were two uterine scar infections in 191 mothers, with no difference between the "natural" cesarean birth group (with skin‐to‐skin contact) and the control group (p = 0.5). Although maternal infection is not an outcome in our review, it is an important topic for future research, as it may explain the reluctance of some clinicians to implement SSC immediately after cesarean birth.

Future researchers in this area can read the other supplementary materials included in this review to understand the existing inconsistencies we noted in the measurement of certain outcomes. Addressing these inconsistencies will facilitate future meta‐analyses. Future studies can use outcome measures consistent with the best measures used in previous studies or measures developed to increase methodological rigor, including core outcome sets where available [1, 21, 141, 142]. Investigators can improve reporting of trial methodology using the CONSORT guidelines (https://www.consort-statement.org) and ensure complete reporting of outcome data. Control of performance bias may continue to be problematic for skin‐to‐skin trials due to requirements for informed consent and the nature of the intervention. As WHO recommends immediate, continuous, uninterrupted SSC as the standard of care, randomizing to separation of mother and newborn may no longer be justifiable.

The current terminology defines immediate skin‐to‐skin contact as beginning before 10 minutes, and early skin‐to‐skin contact as beginning from 10 minutes to 24 hours postbirth. We propose future terminology be changed so that immediate skin‐to‐skin contact means zero to five minutes postbirth, early skin‐to‐skin contact more than five minutes to 20 minutes postbirth, and delayed skin‐to‐skin contact more than 20 minutes to 24 hours postbirth.

Skin‐to‐skin contact is not the same as kangaroo mother care, although they are sometimes used interchangeably in research. Skin‐to‐skin contact refers to immediate or early contact between all mothers and all babies (full term and preterm) during the first hours postbirth, when the naked baby is on the mother's naked abdomen [17]. Kangaroo mother care is a process involving prolonged skin‐to‐skin contact between preterm and low‐birthweight infants and caregivers which ideally starts immediately or as soon as possible after birth, and continues for eight to 24 hours per day, potentially for weeks or months [143].

Breastfeeding exclusivity and success

The use of WHO definitions of breastfeeding and exclusive breastfeeding [1], as well as tools with established reliability to assess breastfeeding, are recommended for use in future clinical trials [142]. The exact dose of skin‐to‐skin contact, start time, and medications given to mothers during labor could impact the infant's breastfeeding behaviors and require documentation. Further, it has been demonstrated that when newborns are placed prone on their mother's chest immediately after birth and left undisturbed, they will progress through Widström's nine stages [10], including self‐attaching to the breast and commencing breastfeeding. Self‐attaching behavior without hands‐on intervention by staff is recommended as the definition of first breastfeeding "success", and impediments to self‐attached suckling require investigation in future studies. Whether Widström's nine stages also occur in preterm infants when placed in skin‐to‐skin contact with their mothers after birth has not been studied and is a subject for future research. If mothers receive some type of breastfeeding support from staff, the nature of the support needs to be described.

Infant physiological stability

For the healthy full‐term newborn and late preterm infant, rigorous and validated composite measures of physiological adaptation during skin‐to‐skin contact are not yet available in the literature. For future use in studies, a validation of the SCRIP (stability of the cardiorespiratory system) score is necessary. Alternatively, other validated measures assessing separate aspects of the stabilization process could be employed and followed over time (heart rate variability, oxygen saturation, respiratory rate). For more vulnerable populations (small for gestational age, large for gestational age, preterm infants, and infants of diabetic mothers), it is important to rigorously evaluate how skin‐to‐skin contact influences blood glucose levels and temperature. For example, researchers should consider the impact of maternal and ambient temperature.

Maternal physiology

Analysis 1.6 in Supplementary material 6 demonstrated little to no effect of skin‐to‐skin contact on placental separation time/length of the third stage of labor. More research is needed on additional aspects of the delivery, including the practitioner's actions during the third stage of labor and maternal medications. Consistent terminology and documentation are needed to distinguish between expulsion and separation.

Postpartum hemorrhage is the leading cause of maternal mortality [144]. Although we did not find a decrease in postpartum blood loss with skin‐to‐skin contact (Analysis 1.11 in Supplementary material 6), more rigorous research is needed, including consistent reliable measurements of blood loss, and documentation of medications, intravenous fluids, and parameters of timing.

Equity‐related implications for research

Health equity research on skin‐to‐skin contact should include evidence‐based practice, education, implementation, and an understanding of challenges to assure appropriate scaling‐up of immediate, continuous, uninterrupted skin‐to‐skin contact in clinical practice worldwide. Known advantages of skin‐to‐skin contact immediately after birth and subsequent exclusive breastfeeding impact maternal and child health and survival. This aligns with the vision of health equity, where opportunities for a healthy life are available to everyone, everywhere. Global research on skin‐to‐skin contact after birth can help decrease health disparities and inequities. Skin‐to‐skin contact is an ideal topic for international health equity‐related research, and fair and just practices for all. Well‐conducted, equity‐focused research may lead to increased uptake of immediate, continuous, uninterrupted skin‐to‐skin contact in all countries. Increasing skin‐to‐skin contact in diverse settings worldwide could increase exclusive breastfeeding rates, which is a goal of international child health policies. Especially in settings with low technology resources, skin‐to‐skin contact provides an opportunity for newborn stabilization, and more research can be conducted to understand the impact on sick and vulnerable infants. Especially in lower income countries, where postpartum hemorrhage levels and maternal death are highest, understanding if there is a connection between skin‐to‐skin contact and lower rates of postpartum hemorrhage could be vital.

Supporting Information

Supplementary materials are available with the online version of this article: 10.1002/14651858.CD003519.pub5.

Supplementary materials are published alongside the article and contain additional data and information that support or enhance the article. Supplementary materials may not be subject to the same editorial scrutiny as the content of the article and Cochrane has not copyedited, typeset or proofread these materials. The material in these sections has been supplied by the author(s) for publication under a Licence for Publication and the author(s) are solely responsible for the material. Cochrane accordingly gives no representations or warranties of any kind in relation to, and accepts no liability for any reliance on or use of, such material.

Supplementary material 1 Search strategies

Supplementary material 2 Characteristics of included studies

Supplementary material 3 Characteristics of excluded studies

Supplementary material 4 Characteristics of studies awaiting classification

Supplementary material 5 Characteristics of ongoing studies

Supplementary material 6 Analyses

Supplementary material 7 Data package

Supplementary material 8 Changes in Methods from the 2016 previous review update

Supplementary material 9 Methods removed from the Methods section of this review update

Supplementary material 10 Definitions of Exclusive Breastfeeding in the included studies

Supplementary material 11 Assessment of the First Breastfeeding

Supplementary material 12 Data for each included study on Placental Separation Time/Length of the Third Stage of Labor

Supplementary material 13 Data for each included study on Intrapartum and/or Postpartum Blood Loss

Supplementary material 14 Practice of safe SSC including preventive actions to avoid Sudden Unexpected Postnatal Collapse (SUPC)

New search for studies and content updated (no change to conclusions)

Additional information

Contributions of authors

EM led the 2007, 2012 and 2016 review updates, and EM and KC co‐lead this update. EM and KC independently reviewed the results of the study search strategies and selected the trials that met the inclusion criteria for this update. All study authors contributed to data curation, including development of the characteristics of included studies table and overview of included studies and synthesis table, risk of bias assessments, and outcome data extraction.

GRADE assessments were completed by EM, KC, KB, and AB. AB and KB entered the outcome data in RevMan, and EM and KC checked it for accuracy. KC wrote the background section of the review, and EM wrote the methods and results sections. The abstract, plain language summary, discussion, and conclusions sections of the review, as well as other supplementary materials, were written and revised by EM, KC, KB, AB, WJ, SL, and KS. All authors conducted a critical review and final editing before publication.

CRediT (Contributor Roles Taxonomy)

Conceptualization: EM, KC
Data curation: EM, KC, KB, AB, WJ, SL, KS, AHA, LRB, JTC, EG, JG, IZG, RH, RRH, MNK, SNM, JS, YT
Formal analysis: EM, KC, KB, AB
Writing—original draft: EM, KC, KB, AB, WJ, SL, KS
Writing—review & editing: EM, KC, KB, AB, WJ, SL, KS, AHA, LRB, JTC, EG, JG, IZG, RH, RRH, MNK, SNM, JS, YT

Gene Anderson was the lead author for the 2003 review. Gene Anderson and Nils Bergman contributed to all previous review updates, including study selection, data extraction, synthesis, and write‐up. N. Medely, an author of the 2016 review, and T. Dowswell, an author of the 2012 review, also contributed to all aspects of the review process.

Declarations of interest

KB, AB, WJ, AHA, EG, JG, MNK, SNM and YT reported that they had no interests (financial or nonfinancial) to disclose at this time. 
LRB is a Nurse‐midwife at BIDPlymouth in Plymouth, MA, USA.
KC is the Healthy Children Project Executive Director.
RRH is the Chairperson of the Training and Assistance for Health and Nutrition Foundation (TAHN) ‐ a voluntary service.
RH is a Family Nurse Practitioner at Regis College.
SL implements skin‐to‐skin contact in her everyday practice at the neonatal units at Karolinska University Hospital.
JS has published on this topic in peer‐reviewed journals and written an article in an Australian midwifery magazine (Midwifery Matters). JS declares posting skin‐to‐skin articles on her Facebook pages and on Twitter.
IZ‐G is a breastfeeding physician in private practice, where she advocates for skin‐to‐skin contact between mothers and babies.
JCT is an Adjunct Professor at Texas Tech University Health Sciences Center School of Nursing, Lubbock, Texas, USA. She received a retainer fee in January 2025 to serve as an expert witness for a court case involving skin‐to‐skin care and breastfeeding following birth. She gave three presentations related to implementing immediate skin‐to‐skin care and received USD 500 per presentation from the Ohio Lactation Consultant Association. 
KS teaches midwifery students and staff and receives a salary for teaching. 
EM and JCT have conducted trials that we included in this review.

• EM conducted Moore 2005, funded by a Dissertation Enhancement Award from Vanderbilt University USA and a Medela Corporation, McHenry IL, USA Research Grant. This study was added to the 2007 review update and evaluated for inclusion by Gene Anderson and Nils Bergman. EM, GA, and NB were the three authors of the 2007 review. Data were extracted and evaluated for risk of bias by GA and NB.

• JTC conducted Crenshaw 2019, funded by a seed grant award from Texas Tech University Health Sciences Center School of Nursing Office of Research, Lubbock. This study was evaluated for inclusion by EM and KC. Data were extracted and evaluated for risk of bias by WJ and YT.

Sources of support

Internal sources

• None, Other

  None

External sources

• Japanese Government, Japan

  Yuki Takahashi received funding from the Japanese government (JSPS KAKENHI grant number 23K10130) for the time she spent working on this review.

• Nagoya University Graduate School of Medicine, Japan

  Employer of Yuki Takahashi during the time she spent working on this review.

Registration and protocol

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

Data, code and other materials

As part of the published Cochrane review, the following is made available for download for users of the Cochrane Library.

• Full search strategies for each database (Supplementary material 1)

• Full citations of each unique report for all studies (included, ongoing or awaiting classification, or excluded during the full‐text screen)

• Study data, including study information, study arms, and study results or test data

• Consensus risk of bias assessments

• Analysis data, including overall estimates and settings, subgroup estimates, and individual data rows.

Appropriate permissions have been obtained for such use. See Supplementary material 7 for the complete data package. Analyses and data management were conducted within Cochrane's authoring tool, RevMan, using the inbuilt computation methods.

What's new

Date	Event	Description
23 October 2025	New search has been performed	We have added 18 authors to this review and 3 authors have discontinued their participation in the review. We added 3 new comparisons and 9 new outcomes, and we deleted 11 outcomes. We also added 26 new trials (Karimi 2014; Agudelo 2021; Al‐Morbaty 2017; Aydin 2022; Crenshaw 2019; Gregson 2016; Gunduz 2023; Hinduja 2014; Kollmann 2017; Liao 2020; Mulupuru 2019; Oksuz 2021; Perez‐Jimenez 2023; Pouraboli 2019; Raj Kumawat 2024; Ramani 2018; Sharma 2016; Solt 2022; Taechavichitpisal 2023; Tosun 2020; Turan 2019; Walsh 2021; Yuksel 2016; Zafran 2019; Zhang 2023; Zou 2022). These trials included 32 articles and 3775 additional participants. We evaluated the risk of bias for blinding (performance and detection bias) for subjective and objective outcomes separately for this review update. We deleted 2 critical outcomes from the summary of findings table (number of mothers breastfeeding, any breastfeeding, 1 to 4 months post birth and duration of any breastfeeding) because we already had 2 outcomes evaluating exclusive breastfeeding in the summary of findings table and added 2 maternal critical physiologic outcomes (placental separation time/duration of the third stage of labor and maternal blood loss in mL – vaginal delivery). A detailed description of the changes to the comparisons and outcomes from the 2016 update and their rationale can be found in Supplementary material 8.
23 October 2025	New citation required but conclusions have not changed	The clinical implications of our findings have not changed for the following outcomes in the SoF table, from those in the 2016 review update: exclusive breastfeeding, infant axillary temperature, blood glucose and SCRIP scores.

History

Protocol first published: Issue 1, 2002
Review first published: Issue 2, 2003

Date	Event	Description
17 December 2015	New search has been performed	We added 12 new studies in this update (Armbrust 2016; Beiranvand 2014; Girish 2013; Luong 2016; Mahmood 2011; Marin 2010; Nahidi 2011; Nasehi 2012; Nimbalkar 2014; Norouzi 2013; Srivastava 2014; Thukral 2012). We added a comparison for women who had a cesarean birth and subgroups exploring dose and time of skin‐to‐skin initiation.
17 December 2015	New citation required but conclusions have not changed	Skin‐to‐skin contact improves breastfeeding in the first months post birth, but limited data and the methodological quality of trials restrict our confidence in findings for infant outcomes. There are no changes to the conclusions from the previous review.
7 March 2012	New search has been performed	The search was updated to 30 November 2011 and, as a result, five randomized controlled trials have been added to the review. 2 of the new studies (Gouchon 2010; Nolan 2009) were conducted with mothers scheduled for repeat cesarean birth using regional anesthesia. 1 study was conducted with hypothermic, but otherwise healthy, newborns postcesarean birth with spinal anesthesia. The results from 4 additional reports involving the data set from Bystrova 2003, 2 additional reports from Anderson 2003, and 1 additional report from Bergman 2004 have been added to this update. In this update we have used new methods and have modified outcomes. 1 trial previously included has now been excluded because quasi‐randomized trials are no longer included.
30 September 2011	New citation required but conclusions have not changed	New author helped to update this review.
8 May 2008	Amended	Converted to new review format.
3 April 2007	New search has been performed	The search was updated to August 2006, as a result of which 17 studies have been added to the review along with 23 clinical outcomes. Additional breastfeeding outcomes include: exclusive breastfeeding up to 4 to 6 months postbirth; starting other feedings before the infant is 2 months of age; success of the first breastfeeding; time to effective breastfeeding; number of breastfeeding problems; frequency of infant mouthing movements with exposure to mother's own milk; and infant body weight change. New outcomes related to maternal feelings and attitudes include: preference for the same postdelivery care in the future; perceptions of the adequacy of her milk supply; self‐confidence about her child care ability; and parenting confidence. 3 studies with late preterm infants who were healthy enough to remain with their mothers on the postpartum unit and between 34 to 37 weeks' gestational age have been added to this review. Additional outcomes related to these infants include: SCRIP scores; number of infants who did not exceed physiological parameters; transfers to the neonatal intensive care unit; and hospital length of stay. A new outcome related to infant behavior is optimal flexed movements. 2 outcomes have also been added evaluating maternal attachment: mean % of maternal contact time and maternal perceptions of bonding/connection to her infant. Although 23 outcomes have been added, there are no significant changes from the conclusions of the previous review.
3 April 2007	New citation required but conclusions have not changed	This review has been substantially updated.