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Major Research Paper:

Prevention of Postpartum Depression Through Maternal Skin-to-Skin Contact

Chloe Harrison (6631303)

BN/MN, Brock University

NURS 4P07 | Pathophysiology and Therapeutics: Common Health Disorders

Dr. Connie Schumacher

May 21, 2024

Preventing Postpartum Depression Through Skin-to-Skin Contact

Postpartum depression (PPD) is characterized in the Diagnostic Statistics Manual V

(DSM-V) as a mood disorder with symptoms ranging from mild to severe. PPD is distinguished

as “the emergence of an episode in the first four weeks in the postpartum period” with symptoms

persisting for up to one year postpartum (Kirca & Adibelli, 2021). Around one in seven women

experience PPD, although, this percentage varies due to the quantity of women who go

undiagnosed without intervention (Mughal et al., 2022). Baby blues is a common postpartum

experience where women often feel sad, worried, and tired after birth, however, these symptoms

usually dissipate after a few days. PPD occurs if these feelings intensify and/or remain for

several weeks postpartum (Office on Women’s Health, 2023). Additionally, PPD is characterized

as a “loss of energy, change in mood, persistent fatigue, thinking that you may not sufficiently

take care of your infant, thinking you may damage your infant, memory weakness, thinking of

self-harm, difficulty in concentrating, appetite problems, sleep problems, social isolation, and the

feeling of inadequacy” (Kirca & Adibelli, 2021).

Mothers with PPD often are more irritable, less sensitive and show less warmth to their

infants. The lack of warmth exhibited to infants from mothers struggling with PPD can influence

their growth and development as well as the mother child interaction experienced during these

early years (Coojimans et al., 2017). Populations at greater risk of developing PPD include those

living in poverty and mothers whose infants are delivered preterm and/or ill. Mothers with PPD

can show disturbances when interacting with their infant, are less responsive, engaged, playful,

and emotional (Bigelow et al., 2012). The lack of responsiveness and synchronicity of mothers

and infants’ results in the inability of infants’ to detect the effect of their own behaviour and

impairs their self-agency abilities as well as socio cognitive functioning (Bigelow et al., 2012).
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Although PPD is a very common mental health disorder experienced by several women,

often PPD goes undetected, undiagnosed, and untreated. Current interventions for PPD include

pharmacological and psychotherapy which can be costly and may harm the infant if the mother is

breastfeeding (Bigelow et al., 2012). Thus, low cost, easily accessible, nursing interventions are

needed to assist these mothers who go undetected, undiagnosed, and untreated. Skin-to-skin

contact (SSC) was initially developed for premature infants when incubators were inaccessible

and infants needed the warmth that is felt for development (Coojimans et al., 2017). Since then,

SSC has been used in a wide variety of settings for mothers and infants to promote mother child

interaction, lessen maternal depression, and increase infants’ vital signs immediately after birth

(Coojimans et al., 2017).

Research Question and Search Methods

This paper addresses the following research question, in first time mothers is the use of

skin-to-skin contact (SSC) between mothers and infants, compared to no skin-to-skin contact

after birth, effective in preventing postpartum depression (PPD)?

A search of the literature was completed on CINHAL Complete as well as MEDLINE –

via OVID. Access to these search engines was made accessible using Brock University’s library

access through a personalized login. When using CINHAL Complete the final search on the

database to retrieve the following articles was “postpartum depression AND skin to skin contact”

which yielded 25 articles between the years of 2001-2024. When limiting the source type to

academic journals, this number was refined to 21 articles. After reviewing the 21 articles to

determine relevancy through titles and abstracts, a total of five articles were chosen from

CINHAL Complete. Upon reading all five articles thoroughly, one was omitted due to a lack of

relevance to the central research questions. After the CINHAL Complete search, MEDLINE –
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via OVID was utilized to search for a final article. The final search on the database to retrieve the

following article was “postpartum depression AND skin to skin contact,” the only limitation

created was the year making the dates between 2001-2024 which yielded 21 articles. Following

review of the titles, one article was chosen to completement the other four articles, which all

directly address the research question. The final article examines risks and preventative measures

related to postpartum depression, directly discussing skin-to-skin contact.

Annotated Bibliography

Bigelow, A., Power, M., MacLellan-Peters, J., Alex, M., & McDonald, C. (2012). Effect of

mother/infant skin-to-skin contact on postpartum depressive symptoms and maternal

physiological stress. Journal of Obstetric, Gynecologic, and Neonatal Nursing : JOGNN.,

41(3), 369–382. https://doi.org/10.1111/j.1552-6909.2012.01350.x

In a longitudinal quasi-experimental study, researchers investigated mothers of full-term

newborns and their feelings of depression through a self-reported depression scale at three

months postpartum. While women experiencing PPD often go undiagnosed as their symptoms do

not reach the threshold for a formal diagnosis; feelings of depression are often the first sign of

PPD which influence a mother’s ability to care for her infant and her responsiveness to her infant

in turn, affecting the infant’s development. The current researchers sought to find an alternative

to treating PPD that was cost effective and easily accessible to all mothers. The current study

investigated the effects of SSC on PPD symptoms and maternal physiological symptoms of

stress through saliva samples later assessed for cortisol. Saliva samples were collected when

infants were one week and one month old. Self-reported depression symptoms were assessed

when infants were one week, one month, two months, and three months of age. The 30 mothers

in the SSC group were asked to provide six hours of SSC with their infant daily for the first week
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after birth, then two hours daily until their infant was one month of age. While the 60 mothers in

the control group were not asked to provide any SSC. Researchers found significant differences

among the two groups; mothers in the SSC group had fewer self-reported PPD scores as well as

reduced physiological symptoms of stress within the first week of birth. Mothers in the SSC

group showed a reduced saliva cortisol level compared to mothers in the control group,

indicating decreased physiological stress one week and one month postpartum. Mothers in the

SSC group also had fewer symptoms of depression compared to mothers in the control groups at

both one week and one month after birth. Overall, it was found through this study that SSC

benefited both mothers and infants, where infants showed reduced crying, better sleep, and were

more physiologically stable, reducing maternal stress postpartum.

Mehler, K., Hucklenbruch-Rother, E., Trautmann-Villalba, P., Becker, I., Roth, B., & Kribs, A.

(2020). Delivery room skin-to-skin contact for preterm infants-A randomized clinical

trial. Acta Pædiatrica., 109(3), 518–526. https://doi.org/10.1111/apa.14975

The preceding study was a randomized control trial examining preterm infants in the

NICU and maternal PPD symptoms, where half of the participants experienced SSC in the

delivery room for one hour continuously before infants were transported to the NICU. The

remaining half of participants participated in only visual contact in the delivery room for five

minutes before infants were transported to the NICU. While preterm infants are at an increased

risk for several neurodevelopmental delays and behavioural disorders; maternal separation

during NICU stays and the added exposure to stress and pain on both the mother and infant place

this population at an increased risk for developing PPD. Researchers examined mother-child

interaction at six months of age when correcting for time spent in the NICU, as well as salivary

cortisol levels in the infants. Mothers in the intervention group were given one hour of delivery
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room SSC, 45 minutes after birth. Mothers in the control group were given five minutes of

delivery room visual contact and were allowed to touch the infants face however, they were not

allowed to unwrap the infant to touch their feet, hands, or body. Mother and infants in the

intervention group showed greater responsive behaviour to one another after maternal

stimulation. The difference in salivary cortisol levels was insignificant however, there was a

significantly higher level of symptoms of depression and poorer quality of bonding between

mothers and infants in the visual contact control group. In mothers in the visual contact control

group, 45% experienced early signs of PPD while only 15% of mothers in the SSC intervention

group experienced early signs of PPD. Infants in the delivery room SSC intervention group

experienced a greater stabilization of vital signs upon arrival to the NICU compared to infants in

the control group. Overall, this additional time that infants and mothers had in the delivery room

to bond before the infant is transported to the NICU may help mothers in decreasing feelings of

anxiety, depression, and increase mother child interaction later which acts as a preventative

measure against neurodevelopmental delays and behavioural problems in preterm NICU infants.

Kirca, N., & Adibelli, D. (2021). Effects of mother–infant skin‐to‐skin contact on postpartum

depression: A systematic review. Perspectives in Psychiatric Care, 57(4), 2014–2023.

https://doi.org/10.1111/ppc.12727

A systematic review was conducted to determine the effects of mother-infant SSC on

PPD. There were three stages conducted in this systematic review; cardiovascular disease was

assessed, SSC was assessed, and salivary cortisol levels were assessed in all studies analyzed.

Additionally, maternal stress, depression, anxiety, and traumatic stress were evaluated; while

infant’s crying, sleep quality, growth, health, development, and physiological stress were

evaluated. Many have found that SSC instigates the release of oxytocin which blocks the stress
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response reducing maternal stress and depression. Additionally, the World Health Organization

states that SSC should be encouraged and started promptly following delivery of the infant.

Moreover, SSC increases bonding between mothers and infants and provides several benefits

post-delivery, including a faster removal of the placenta and an increase in maternal self-efficacy

when initiating breast feeding. It was found that mothers in SSC groups made positive

contributions to PPD, infants had lower salivary cortisol levels which correlated with mothers’

salivary cortisol levels, and mothers had lower scores on depression and PPD scales. Overall, it

was found that SSC between mothers and infants provided benefits in decreasing maternal PPD

and depression ratings on scales as well as reducing infant and mother physiological stress as

observed through salivary cortisol levels. Therefore, SSC is a cost effective, easily accessible,

and effective nursing intervention that can provide both the mother and infant with several

mental and physical benefits upon intervention and in the future.

Cooijmans, K. H. M., Beijers, R., Brett, B. E., & de Weerth, C. (2022). Daily mother-infant skin-

to-skin contact and maternal mental health and postpartum healing: a randomized

controlled trial. Scientific Reports, 12(1), 10225–10225. https://doi.org/10.1038/s41598-

022-14148-3

A randomized control trial was conducted to test SSC and its relation to maternal anxiety,

depression, stress, fatigue, and pain; five, twelve, and fifty-two weeks postpartum. Where

mothers and infants in the intervention group were instructed to participate in one continuous

hour of SSC daily for five weeks starting at birth to examine the effects of maternal PPD

symptoms one year later. Of all participants, 4-15% reported depressive symptoms that reached

clinical cut off and 8-15% reported anxiety symptoms that reached clinical cut off. Those in the

SSC group experienced a decrease in symptoms of fatigue as the weeks went on while, those in
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the control group showed a decrease from weeks two to five but then an increase at week twelve.

When comparing maternal anxiety between groups, there was a significant interaction over time.

This study found no significant decrease or prediction of maternal depression, anxiety, stress,

fatigue, and pain in the intervention group of SSC with newborns and mothers. However, this

study also did not have good adherence rates where the SSC intervention group did not follow

through with one continuous hour of SSC between mothers and infants every day. Only 17 out of

56 participants provided one continuous hour of SSC daily for at least 28 of the 35 intervention

days. Therefore, there were also no significant findings at the 52 week follow up assessments.

While these findings do not support the central research question, it is important to include data

that may not support the research question to ensure transparency in research methods as well as

improve and direct future research methods.

Lin YH, Chen CP, Sun FJ & Chen CY (2022). Risk and protective factors related to immediate

postpartum depression in a baby-friendly hospital of Taiwan. Taiwanese Journal of

Obstetrics & Gynecology, 61(6), 977-983. https://dx.doi.org/10.1016/j.tjog.2022.08.004

This cross-sectional study aimed to investigate factors associated with PPD at just 48

hours postpartum. Several studies have found mood disturbances relating to PPD within just

three days postpartum while, PPD symptoms just one week postpartum have been linked to an

increase in PPD four to eight weeks following. Additionally, the symptoms of PPD that present

24-48 hours postpartum have been linked to depression, anxiety, and suicidal ideation. Through

baby-friendly hospitals that were introduced by the World Health Organization and the United

Nations Children’s Fund, that foster optimal clinical care, support, and protective factors such as

breast feeding for mothers; these researchers were able to identify factors associated with

immediate PPD through the investigation of depression rating scales that mothers completed just
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48 hours postpartum. The results of these rating scales were obtained, and through analyzation,

protective and risk factors associated with PPD were identified. It was found that, risk factors for

PPD included traumatic birthing experiences such as previous miscarriages, emergency

caesarean delivery, gestational hypertension and preeclampsia, placenta previa, postpartum

hemorrhage, and infant admission to NICU after birth. While protective factors for developing

PPD include the father/husband being present in the delivery room, the birth being a planned

pregnancy, those with early SSC and those who were breastfeeding. While early SSC with the

mother and newborn provide many benefits, those observed include that the mothers’ anxiety

was reduced, there was an increase in satisfaction of the birthing experience and breast feeding,

the infants vital signs stabilized, and SSC provides stimulation for the release of oxytocin

through the activation of sensory neurons. Therefore, SSC acts as a preventative measure in the

prevention of PPD.

Synthesis of Summary

Overall, it was found through the five studies that SSC acted not only as a protective

factor in the prevention of PPD but also as a way of decreasing feelings of anxiety, depression,

fatigue, stress, and physiological stress in new mothers. While infants also felt the effects

through stabilization of vital signs immediately following birth to a reduction in physiological

stress assessed through salivary cortisol testing (Mehler et al., 2020). Additionally, mother child

interactions were observed in several studies and those who experienced SSC postpartum tended

to have a greater bond than those that did not (Kirca & Adibelli, 2021). While one study by

Cooijmans et al. (2022) found contradicting results; a more thorough investigation through the

preceding search engines may result in this article being removed due to a lack of adherence to

study protocols influencing the results of the randomized control trial. A more thorough search
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through the search engines is needed to determine if these results were due to in-adherence or

because one hour of SSC does not provide the benefits that a longer duration of SSC might. As

Bigelow et al. (2012) study suggests that six hours of SSC the first week after birth with two

hours for the preceding weeks yields significant findings in reduction of depressive symptoms in

mothers. Additionally, Lin et al. (2022) study suggests that SSC between infants and mothers

postpartum is a protective factor against PPD.

The research question guiding the search was in first time mothers is the use of skin-to-

skin contact (SSC) between mothers and infants, compared to no skin-to-skin contact after birth,

effective in preventing postpartum depression (PPD)? Through the evaluation of five peer-

reviewed journal articles, it can be hypothesized that SSC does prevent PPD. Future research

should focus on the exact aspect of PPD that SSC acts as a buffer against. Additionally, future

research should investigate further the amount of SSC needed between mothers and infants to act

as a protective measure against PPD. Lastly, future research should focus on the act of SSC

directly after birth versus hours or days after birth and the effects on PPD based on the specific

timing of SSC.

Conclusion

In conclusion, the preceding broad search of the literature to investigate the influence of

SSC on PPD was successful in identifying what is currently known about the topic. While PPD

is known to influence the care mothers can provide for their infant, infants development and

bonding is influenced by the mothers’ experience with PPD. Infants whose mothers struggle with

PPD are at an increased risk of developing developmental disabilities including those that

influence cognitive, social, and emotional aspects of development. While mothers with PPD

often show deficits in their ability to interact with their infant and provide the infant with the
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responsive, sensitive, and emotional warmth infants need. SSC is a cost-effective, easily

accessible method that could be used to not only improve maternal PPD symptoms but also

positively influence the infant and their development. Therefore, more research is needed to

determine the exact effects of SSC on PPD and how SSC can be an influential way of preventing

and treating PPD in mothers.

References

Bigelow, A., Power, M., MacLellan-Peters, J., Alex, M., & McDonald, C. (2012). Effect of

mother/infant skin-to-skin contact on postpartum depressive symptoms and maternal

physiological stress. Journal of Obstetric, Gynecologic, and Neonatal Nursing : JOGNN.,

41(3), 369–382. https://doi.org/10.1111/j.1552-6909.2012.01350.x

Cooijmans, K. H. M., Beijers, R., Rovers, A. C., & de Weerth, C. (2017). Effectiveness of skin-

to-skin contact versus care-as-usual in mothers and their full-term infants: study protocol

for a parallel-group randomized controlled trial. BMC Pediatrics, 17(1), 154–154.

https://doi.org/10.1186/s12887-017-0906-9

Cooijmans, K. H. M., Beijers, R., Brett, B. E., & de Weerth, C. (2022). Daily mother-infant skin-

to-skin contact and maternal mental health and postpartum healing: a randomized

controlled trial. Scientific Reports, 12(1), 10225–10225. https://doi.org/10.1038/s41598-

022-14148-3

Kirca, N., & Adibelli, D. (2021). Effects of mother–infant skin‐to‐skin contact on postpartum

depression: A systematic review. Perspectives in Psychiatric Care, 57(4), 2014–2023.

https://doi.org/10.1111/ppc.12727

Lin YH, Chen CP, Sun FJ & Chen CY (2022). Risk and protective factors related to immediate

postpartum depression in a baby-friendly hospital of Taiwan. Taiwanese Journal of

Obstetrics & Gynecology, 61(6), 977-983. https://dx.doi.org/10.1016/j.tjog.2022.08.004

Mehler, K., Hucklenbruch-Rother, E., Trautmann-Villalba, P., Becker, I., Roth, B., & Kribs, A.

(2020). Delivery room skin-to-skin contact for preterm infants-A randomized clinical

trial. Acta Pædiatrica., 109(3), 518–526. https://doi.org/10.1111/apa.14975

Mughal, S., Azhar, Y., & Siddiqui, W. (2022). Postpartum Depression. StatPearls [Internet].

https://www.ncbi.nlm.nih.gov/books/NBK519070/

Office on Women’s Health. (2023, October 17). Postpartum depression. Office on Women’s

Health in the U.S. Department of Health and Human Services

https://www.womenshealth.gov/mental-health/mental-health-conditions/postpartum-

depression
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NURS 4P07: Major Paper (20%)

This paper provides you with an opportunity to explore an area of focus appropriate to the
topics in this course from the perspective of research evidence and an area of research interest
for you. You will select a topic of interest, develop a searchable question, provide library search
terms, an annotated bibliography of five peer reviewed publications, and a synthesis summary
of the publications. The summary will indicate how the publications addressed your question as
well as future directions for research in this area.
Length: maximum of eight pages, not including title page or references
Format: APA 7th Edition
Name:__________________________________

Criteria Comments
Research Topic
Identification of research topic. Justification and
reasoning for research topic.
Research Question
Follow PICO
10 Marks

Application - Scientific Evidence

Annotated Bibliography
To include 5 peer reviewed publications
10 Marks

Synthesis Summary
Include the 5 peer reviewed publications, relate to
your research question, future implications.
10 Marks
Organization and Communication:
Spelling, grammar, sentence structure, clarity and
flow of ideas. Introduction/Conclusion.
APA referencing & format
5 Marks
Total mark /40

Marks for each section are weighted by criteria and quality of work.