Effect of Combined Skin-to-Skin Contact and Kangaroo Care on Breastfeeding and Bonding in Cesarean-Born Newborns

The global increase in cesarean section rates has become a significant public health concern. In Türkiye, the cesarean section rate reached 57.4% in 2023, one of the highest among OECD countries. Babies born by cesarean section are often deprived of early skin-to-skin contact in the immediate postnatal period due to maternal physical limitations, which may negatively affect breastfeeding outcomes and parent-infant bonding.

Skin-to-skin contact and kangaroo care are evidence-based practices known to support neonatal physiological stability, breastfeeding success, pain management, and parent-infant bonding. However, operational and clinical barriers following cesarean delivery often limit the early implementation of maternal skin-to-skin contact. While the effects of skin-to-skin contact have been extensively studied in the context of mother-infant dyads, evidence regarding father-infant skin-to-skin contact remains limited, particularly in term infants.

Delayed maternal contact following cesarean delivery may result in missed opportunities for early bonding and breastfeeding initiation. In this context, involving fathers in early skin-to-skin contact may provide an effective strategy to compensate for delayed maternal contact. Active paternal participation in newborn care has been shown to support infant development, enhance paternal role adaptation, and strengthen family bonding.

This randomized controlled study will be conducted in the delivery and postpartum units of a private mother- and baby-friendly hospital in Istanbul, Türkiye. The study population will consist of mothers and term newborns born by cesarean section who meet the inclusion criteria. Sample size will be determined using G*Power software.

Participants will be randomly assigned to one of two groups. In the intervention group, newborns will receive uninterrupted skin-to-skin contact with the father for 30 minutes immediately after birth. Painful procedures, including hepatitis B vaccination and vitamin K administration, will be performed during father-infant skin-to-skin contact. Following maternal recovery and confirmation of clinical suitability, consecutive skin-to-skin contact will be initiated between the mother and the newborn. The first breastfeeding attempt will occur during maternal skin-to-skin contact.

The control group will receive routine postnatal care according to the hospital's standard protocol.

Breastfeeding success will be assessed using the Bristol Breastfeeding Assessment Tool prior to discharge, on postpartum day 2, and at one month postpartum. Maternal and paternal bonding will be evaluated using the Maternal Postnatal Attachment Scale (MPAS) and the Paternal Postnatal Attachment Scale (PPAS) at the same time points. Breastfeeding parameters and parental bonding outcomes will be statistically compared between the two groups.

Inclusion criteria

• Mothers who delivered by cesarean section
• Mothers and fathers willing to participate and provide written informed consent
• Newborns who are stable after birth
• No health conditions in mothers or fathers that would prevent participation in skin-to-skin contact

Exclusion criteria

• Serious maternal or neonatal illness
• Newborns requiring NICU admission
• Mothers or fathers unwilling to participate
• Any maternal or paternal condition preventing the implementation of skin-to-skin contact

Additional note:

-Eligibility is based on biological sex (female for mothers, male for fathers, newborns of any sex), not on gender identity.