Facilitators and challenges in the practice of skin-to-skin contact after birth: a scoping review protocol

Abstract

Introduction

Neonatal survival continues to pose a global health challenge. Skin-to-skin contact (SSC) has been shown to significantly reduce neonatal mortality and offer numerous benefits for both mothers and newborns. However, its implementation varies widely across healthcare settings and is often hindered by practical barriers. This scoping review aims to systematically explore the facilitators and challenges associated with implementing SSC after birth and to synthesise relevant evidence to guide clinical practice.

Methods and analysis

This scoping review will follow the Joanna Briggs Institute methodological framework for scoping studies. A comprehensive search will be conducted across seven electronic databases and grey literature sources. Two review authors will independently perform the screening of studies and data extraction in parallel. Discrepancies will be resolved through consensus or consultation with a third author. A data extraction form will be developed based on key themes related to SSC implementations. The extracted data will be qualitatively analysed and presented in diagrammatic, tabular and narrative summary forms, in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: Extension for Scoping Reviews reporting guidelines.

Ethics and dissemination

All data to be used in this study will be derived from previously published studies, thus rendering the need for ethical approval and informed consent superfluous

Registration

This protocol has been registered in Open Science Framework (https://doi.org/10.17605/OSF.IO/CWPK4).

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• A thorough systematic search of databases and grey literature will ensure identification of all available evidence.

• This review will strictly follow the Joanna Briggs Institute methodological framework for scoping studies.

• Two reviewers will independently screen studies and extract data, reducing bias.

• No formal assessment of methodological quality or risk of bias will be conducted, potentially weakening evidence robustness.

• Only studies published in English will be included, risking omission of high-quality non-English literature and introducing language bias.

Introduction

Neonatal survival remains a critical global challenge. According to the UNICEF 2023 report, approximately 4.9 million children under 5 years of age died globally, with nearly half being neonates.¹ The transition from the intrauterine to the extrauterine environment is a complex physiological change for newborns. During this critical period, their relatively large surface-area-to-volume ratio places them at a high risk of rapid heat loss, which can quickly lead to hypothermia, a condition strongly associated with increased neonatal morbidity and mortality.^{2 3} To prevent hypothermia and its complications, the WHO’s Early Essential Newborn Care (EENC) guidelines recommend immediate skin-to-skin contact (SSC) between mother and infant immediately after birth.⁴ SSC is defined as placing the naked newborn prone on the mother’s bare chest immediately after birth, with continuous contact for at least 1 hour or until the first successful breastfeeding.^{5 6} SSC promotes neonatal physiological stability by establishing maternal-neonatal temperature synchrony, which facilitates optimal thermal regulation and effectively mitigates the risk of hypothermia.⁷

In addition to the thermal insulation effect brought by direct naked contact, SSC confers multiple physiological and developmental benefits for both mothers and newborns.⁸ Growing evidence has confirmed that SSC significantly improves breastfeeding outcomes through multiple synergistic pathways. Newborns in SSC exhibit innate behaviours, guided by olfactory and taste cues, that lead them to the breast. Studies showed that longer durations of SSC are associated with higher rates of exclusive breastfeeding at hospital discharge and after discharge.⁹ A positive cycle mechanism is that SSC-induced tactile stimulation may boost maternal oxytocin release, thereby enhancing both milk production and ejection efficiency.¹⁰ Physiologically, SSC also stabilises cardiorespiratory function. Newborns receiving SSC demonstrate more mature heart rate variability patterns and more regular breathing, reflecting reduced stress and better autonomic regulation.¹¹ In addition, SSC has demonstrated it can provide measurable neuroprotection by reducing stress hormones and enhancing autonomic nervous system regulation.¹² It also reinforces the mother-infant bond via oxytocin-mediated pathways, which has been linked to reduced postpartum anxiety in mothers.¹² Notably, SSC correlates with superior long-term developmental outcomes.^{12 13} For mothers, the current review has confirmed that SSC benefits in the prevention of postpartum haemorrhage by reducing the duration of the third stage of labour.¹⁴ The summary of the systematic review also indicates potential benefits of SSC in perceptions of bonding to newborns, post-caesarean pain, sensitivity to infant cues and parenting confidence for mothers.¹⁵

However, the global implementation of SSC is not ideal. A survey in Cambodia and the Lao People’s Democratic Republic revealed low adoption rates of SSC within 15 min after birth.¹⁶ In addition, the implementation criteria in certain hospitals do not strictly align with EENC guidelines, including SSC.¹⁷ Although the obvious benefits of SSC are recognised, healthcare providers’ limited endorsement has been noted.¹⁸ In addition, according to qualitative findings, challenges, including staff shortages, time constraints, ambiguities in SSC eligibility criteria, safety concerns, disruptions to clinical workflows and interdepartmental coordination issues, have impeded SSC implementation.19,22 An observational study further highlights that concerns over neonatal infections have restricted the widespread adoption of early SSC.²³ While studies have raised facilitators and barriers to SSC, a systematic synthesis is still lacking. Fitriana conducted a systematic review that explored both enablers and obstacles to SSC but only included seven studies.²⁴ As EENC has been increasingly promoted in low- and middle-income countries in recent years,25,27 it is likely that new and context-specific barriers and facilitators have emerged in different countries during SSC implementation. In addition, our literature review found that most existing studies have focused primarily on preterm infants treated with Kangaroo Mother Care rather than on term neonates delivered vaginally. To improve maternal and neonatal outcomes, there is an urgent need to gain a thorough understanding of these determining factors. Identifying context-specific facilitators and barriers across various healthcare settings will support the development of tailored interventions, thereby enhancing the global implementation of SSC. Therefore, this scoping review aims to systematically review the facilitators and challenges encountered during SSC implementation and to synthesise existing evidence to inform clinical practice.

Research questions

• What are the key facilitators that promote the successful implementation of SSC after birth?

• What are the primary barriers that hinder the effective practice of SSC in clinical settings?

• How do these facilitators and barriers vary across different demographic groups and healthcare systems?

Objectives

• To systematically identify and describe the factors that facilitate the adoption and sustained practice of SSC.

• To comprehensively summarise the barriers to SSC implementation in various clinical contexts.

• To develop evidence-based recommendations for addressing implementation barriers and enhancing SSC integration into routine postnatal care.

Methods and analysis

To ensure methodological rigour and transparency, this protocol has been registered on the Open Science Framework (https://doi.org/10.17605/OSF.IO/CWPK4). Its development followed the best practice guidance established by the Joanna Briggs Institute (JBI) Scoping Review Methodology Group.²⁸ The review will be conducted in accordance with the JBI scoping review framework²⁹ and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: Extension for Scoping Reviews (PRISMA-ScR),³⁰ ensuring comprehensive and transparent evidence synthesis.

The implementation of this scoping review will involve nine key steps^{28 29}: (1) defining and refining the aims and research questions; (2) establishing eligibility criteria based on the review’s objectives and research questions; (3) developing a detailed strategy for literature search and selection; (4) conducting the literature search; (5) screening and selecting relevant studies; (6) systematically extracting data from the included studies; (7) charting the extracted data; (8) synthesising the findings in relation to the research aims and questions and (9) consulting with information specialists and subject matter experts to ensure methodological rigour and relevance.

Search strategy

The objective of this search strategy is to identify both published and grey literature relevant to the topic. A comprehensive systematic search will be conducted across seven electronic databases: PubMed, Scopus, Embase, the Cochrane Library, CINAHL, ASSIA (ProQuest) and Web of Science. The search strategy will be tailored for each database, incorporating relevant keywords and controlled vocabulary as appropriate. Additionally, efforts will be made to identify grey literature by searching relevant repositories and sources.

An initial limited search of PubMed was conducted to identify key articles on the subject. The text words contained in the titles and abstracts of relevant studies, along with the index terms used to describe them, were analysed to inform the development of a comprehensive search strategy. The PubMed search strategy is presented in table 1. Boolean operators were employed to enhance the sensitivity and specificity of the search.

Table 1. Search strategy for PubMed.

Number	Query
1	skin to skin*(Title/Abstract)OR skin-to-skin*(Title/Abstract)OR skin to skin contact(Title/Abstract)OR skin-to-skin contact(Title/Abstract)OR chest to chest*(Title/Abstract)OR chest-to-chest*(Title/Abstract)OR skin contact(Title/Abstract)OR mother-infant contact(Title/Abstract)OR essential newborn care(Title/Abstract)OR essential neonatal care(Title/Abstract)OR early essential newborn care(Title/Abstract)
2	Infant(Title/Abstract)OR newborn(Title/Abstract)OR birth(Title/Abstract)OR childbirth(Title/Abstract)
3	factor*(Title/Abstract)OR barrier*(Title/Abstract)OR hinder*(Title/Abstract)OR hindrance*(Title/Abstract)OR obstacle*(Title/Abstract)OR enabl*(Title/Abstract)OR challeng*(Title/Abstract)OR adher*(Title/Abstract)OR facilit*(Title/Abstract)OR difficult*(Title/Abstract)OR attitude(Title/Abstract)OR effect*(Title/Abstract)OR influenc*(Title/Abstract)OR practice(Title/Abstract)OR implement*(Title/Abstract)OR role(Title/Abstract)OR qualitative(Title/Abstract)OR interview(Title/Abstract)OR survey(Title/Abstract)OR “mixed method*"(Title/Abstract)OR manage*(Title/Abstract)OR readiness(Title/Abstract)OR perspective(Title/Abstract)OR opinion*(Title/Abstract)OR view*(Title/Abstract)OR perception*(Title/Abstract)OR experience*(Title/Abstract)OR motivation(Title/Abstract)OR motivat*(Title/Abstract)OR promot*(Title/Abstract)OR adheren*(Title/Abstract)OR bottleneck*(Title/Abstract)
4	1 and 2 and 3

Inclusion and exclusion criteria

The eligibility criteria were established according to the methodological guidelines of JBI, clarifying the Population, Concept and Context.²⁹ Studies will be incorporated in this review if they satisfy the specified conditions.

Participants

This review will consider studies involving women of reproductive age (typically aged 18–45 years) who gave birth to live infants, regardless of gestational age, mode of delivery (including vaginal birth and caesarean section) or parity. Studies involving individuals with severe psychiatric conditions, significant maternal complications (eg, uncontrolled postpartum haemorrhage or infection) or whose newborns experienced major adverse outcomes (eg, neonatal asphyxia or neonatal intensive care unit admission) will be excluded.

Concept

The core concept of this review is the identification of facilitators and barriers related to the implementation of SSC between mother and newborn during the immediate postnatal period (typically within the first hour after birth). Included studies must describe at least one factor influencing SSC practice, such as provider knowledge and attitudes, institutional policies, workflow challenges, cultural or familial factors or physical and environmental conditions. Studies solely reporting health outcomes of SSC (eg, hypothermia prevention, breastfeeding success) without exploring implementation-related factors will be excluded. In addition, studies that do not address the initiation of SSC within the first hour after birth and focus solely on Kangaroo Mother Care in neonatal intensive care units will also be excluded.

Context

This review will include studies conducted in any geographic location and across all healthcare settings, including hospitals and birthing centres.

Types of studies

This review will consider primary research studies using quantitative, qualitative or mixed-methods designs, as well as relevant systematic reviews, scoping reviews, dissertations and theses. Both peer-reviewed and grey literature will be included, provided that the full text is available in English or an English translation is accessible. Conference abstracts, study protocols, editorials and commentaries will be excluded. The literature search will include studies published up to 31 December 2025.

Study selection

Following the literature search, all potentially relevant studies will be imported into EndNote V.X9, and duplicate records will be removed. Two reviewers will independently screen the titles and abstracts of all retrieved citations to assess their relevance and determine eligibility based on the predefined inclusion criteria. Full texts of studies deemed potentially eligible will then be retrieved and assessed in detail by the same reviewers. Any discrepancies during the selection process will be resolved through discussion, and if consensus cannot be reached, a third reviewer will be consulted. The final scoping review will present the results of the selection process using a PRISMA-ScR flow diagram to illustrate the inclusion and exclusion of studies (figure 1).

Figure 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram illustrating the selection of systematic reviews.

Data extraction and synthesis

Data from the included evidence sources will be independently extracted by two reviewers using a pre-designed data extraction tool. The extracted data will include details such as the first author and year of publication, country of origin, research objectives, study design, participant characteristics, key concepts, context, sample size, identified facilitators and barriers and other findings relevant to the research questions. A draft version of the data extraction tool is presented in table 2. This tool will be refined iteratively as needed throughout the data extraction process, and all modifications will be clearly documented in the final scoping review. Any disagreements arising during data extraction will be resolved through discussion, or if necessary, by consulting a third reviewer. If required, corresponding authors will be contacted to obtain missing or supplementary information.

Table 2. Draft data extraction tool.

Citation details

Study design

Participants

Concept

Context

Sample size

Facilitators

Barriers

Key findings

Data analysis and presentation

Data analysis will primarily consist of fundamental descriptive analysis. The findings will be systematically presented in tables and/or diagrams aligned with the objectives of the review. A narrative summary will accompany the tabulated and visualised data to further explain and contextualise the results in relation to the review’s primary objectives and research questions. As this is a scoping review, no formal assessment of methodological quality or risk of bias will be conducted.

Ethics and dissemination

As this scoping review will involve the analysis of data from publicly available sources and will not include any human participants directly or the collection of personal data, ethical approval is not required. The findings of this review will be disseminated through publication in a peer-reviewed journal and may also be presented at relevant academic conferences. The results will be shared with stakeholders, including medical professionals, educators and policymakers, to inform evidence-based practice and guide future research related to the implementation of SSC.