{'fraction_non_alphanumeric': 0.028756681845179172, 'fraction_numerical': 0.010690952286675905, 'mean_word_length': 5.300280636108512, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Women’s experiences of skin-to-skin cesarean birth compared to standard cesarean birth: a qualitative study

Background: Skin-to-skin contact between mother and infant immediately after birth is recommended regardless of delivery method; however, it is less common after cesarean delivery. We aimed to describe and compare women’s experiences of cesarean birth with and without skin-to-skin contact at an urban tertiary care hospital. Methods: In this hermeneutic phenomenologic study, we used semistructured telephone interviews from 2015 to 2018 to interview a convenience sample of women who delivered at term by scheduled skin-to-skin cesarean birth at an urban tertiary care hospital in Toronto, Ontario. Women were invited to participate if they had had a previous planned or unplanned cesarean birth and a scheduled skin-to-skin cesarean birth between 2013 and 2017. Participants were excluded if they had antenatally diagnosed conditions, they delivered before 37 weeks, they had general anesthesia, their condition was unstable at the time of surgery, a skin-to-skin cesarean birth was not possible or they declined skin-to-skin cesarean birth. Interviews were recorded, transcribed and analyzed by means of thematic analysis. Results: Ten women were interviewed 1–19 months postpartum. Four central themes emerged: support for skin-to-skin cesarean birth (women feeling supported by their families and health care providers); control (participants experiencing greater control during their skin-to-skin cesarean birth); connection with the infant, which enabled women to be active participants in their delivery, enhanced bonding and intimacy, facilitated breastfeeding and bolstered confidence during early parenthood; and logistic considerations, with participants recognizing that skin-to-skin cesarean birth required additional resources. Interpretation: These findings refine what is known about skin-to-skin cesarean birth and provide a critical perspective, that of mothers. They support the transformation of traditional operating room dynamics to a more patient-centred environment.

concern is contamination of the sterile field and the risk of increased surgical site infections; however, a study of infection rates after skin-to-skin cesarean birth showed no increased risks, 26 and new surgical drapes are designed specifically to facilitate skin-to-skin cesarean birth without contamination of the sterile field. 27 There has also been criticism around referring to major surgery as a "natural" procedure. 28 However, evidence suggests that, from the patient's perspective, skin-toskin cesarean birth enhances the maternal experience of an uncomplicated cesarean birth 23,29 by offering a family-centred option 30,31 that gives birth back to women and babies.
In addition to these well-documented barriers, other practical concerns that may complicate the provision of skin-toskin contact after cesarean birth include the lack of a standardized protocol, 32 nursing staff availability, 33 maternal or neonatal instability, 34 type of anesthetic, 35 support from anesthesia, 35 clinician education, 32 and the challenge of practice and behaviour changes in a busy clinical environment. 25 This study's purpose was to describe maternal experiences of cesarean birth with and without skin-to-skin contact at an urban tertiary care hospital. A better understanding of such experiences will be critical when deciding to implement skinto-skin contact after cesarean birth whenever safely possible.

Study design and setting
We conducted a hermeneutic phenomenologic study using semistructured telephone interviews to identify and describe common themes from women's experiences of cesarean birth with and without skin-to-skin contact at Sunnybrook Health Sciences Centre, an urban tertiary care hospital in Toronto, Ontario.
We chose phenomenology as the study design because its goal is to understand the essence of social phenomena from those with lived experience. 36 This study used a hermeneutic approach, as described by van Manen, 37 to phenomenologic inquiry since this allowed for the construction of multiple realities, 38 which was particularly salient as mothers may have had very different experiences with their earlier, non-skin-toskin cesarean deliveries.
The study team consisted of a family physician (C.A.M.) with a special interest in the skin-to-skin cesarean birth technique, a research manager (S.E.O.) with substantial skin-toskin research experience, a registered nurse (G.B.) with expertise in Sunnybrook Health Sciences Centre's policy on the skin-to-skin birth method, a qualitative health research expert (W.H.M.) and the obstetrician-gynecologist (J.F.R.B.) who introduced the skin-to-skin cesarean birth method to Canada. Reflexivity, defined as self-reflection and self-criticism, is based on the premise that researchers are an active part of the research setting, relationship and interpretations, 39 and, specifically within hermeneutic research, researchers are part of the hermeneutic circle. 40 As such, C.A.M. and S.E.O. continually examined their beliefs, assumptions and motivations, and how these affected their research. 41 For example, C.A.M. was born extremely prematurely via emergency cesarean delivery and did not experience immediate skin-to-skin contact with her mother. This inspired her master's thesis, 42 which examined the differences between skin-to-skin and standard cesarean birth. As such, careful consideration of how her experiences came to bear on this study was required. In addition, S.E.O. was involved in several concurrent skin-to-skin research projects, which required constant reflexivity about potential crossover impacts.

Participants
Inclusion criteria for participation comprised a previous planned or unplanned cesarean birth and a scheduled skin-toskin cesarean birth between 2013 and 2017 at Sunnybrook Health Sciences Centre. Women with low-risk pregnancies and a scheduled cesarean birth under spinal or epidural anesthesia were asked before or after delivery whether they would be interested in participating. We used a convenience sample, 43 with potential participants introduced to the study by their primary obstetrician (J.F.R.B.) and written consent obtained by the study team. After delivery, participants were excluded if there were antenatally diagnosed conditions such as genetic abnormalities, they delivered before 37 weeks, they had general anesthesia, their condition was unstable at the time of surgery, skinto-skin cesarean birth was not possible (i.e., the infant required resuscitation) or they declined skin-to-skin cesarean birth. Once participant eligibility was confirmed, interviews were conducted by 2 members of the study team (C.A.M., S.E.O.), neither of whom was engaged in the clinical care of the participants. Before each interview, verbal consent was obtained and participants answered demographic questions. Although the interview questionnaire was used as a guide, each interview required a tailored approach dependent on individual responses.

Data collection
The interviews were recorded digitally, transcribed with identifying information removed and reviewed (C.A.M., S.E.O.) for accuracy.

Data analysis
The data were analyzed by 2 study team members (C.A.M., S.E.O.) using Braun and Clark's 44 approach to thematic analysis. First, they familiarized themselves with the data by rereading each transcript and noting preliminary ideas. They then generated initial codes from the transcripts using the participant's language. The codes were collated into potential themes, which were reviewed and then refined in the context of the overall narrative, after which a final report was produced. Data collection and analysis were iterative and simultaneous. When preliminary codes and themes began to repeat and no novel ideas emerged, it was determined that data saturation had been reached and data collection stopped. 36

Data credibility
We used several strategies to enhance the credibility of the data. First, the researchers were reflexive and reflected on their personal perspectives throughout the study. 45 Second, member checking confirmed that the themes that developed from the analysis showed the broadest range of experiences possible. This was carried out by summarizing the major themes and presenting them back to participants with a request for feedback, clarification and confirmation that their experiences had been conveyed adequately. 36,45 Finally, auditability ensured that the research process and methodology were clearly outlined from the start and that evolving themes were discussed within the research team to ensure consensus. 45

Ethics approval
The Sunnybrook Health Sciences Centre Research Ethics Board approved this study (no. 449-2014).

Results
Ten women who met our inclusion criteria participated. Five women who had consented were excluded after delivery (general anesthetic was given in 1 case, and skin-to-skin cesarean birth was impossible in 4 cases). The mean age of the participants was 36.9 (range 30-41) years. Other demographic information is provided in Table 1.
Four central themes emerged from the analysis: support for skin-to-skin cesarean birth, control, connection with the infant and logistic considerations ( Table 2).

Support for skin-to-skin cesarean birth
All participants reported feeling supported practically and emotionally by their families and the medical team in their decision to pursue a skin-to-skin cesarean delivery and during the birth itself.

Control
Participants experienced a shifting locus of control with skinto-skin cesarean birth compared to standard cesarean delivery. There was a clear sense of empowerment with skin-to-skin cesarean birth, with participants remarking it enabled them to be active members in their delivery and during the first hours of parenting.
This feeling of control in their birth experience also affected participants' sense of self. Almost all participants carried some guilt or shame for having had a cesarean birth, regardless of the indication. Some stated that societal attitudes about cesarean birth hindered their perception of self as mothers. However, this was, in some ways, restored by skinto-skin cesarean birth, perhaps through their engagement in the procedure or as they comforted their infant on the operating room table. Several participants said that the concept of identifying as a mother through skin-to-skin cesarean birth was important in bolstering their confidence in the early moments of parenthood.

Connection with infant
Skin-to-skin cesarean birth enabled maternal connection and intimacy with the infant. All 5 participants who had completed their first year postpartum at the time of their interview mentioned the intangible sense of closeness that carried through the first year of mothering their child born by skin-to-skin cesarean delivery. They felt that, in a way, their skin-to-skin cesarean birth replicated a vaginal birth, and several participants were disappointed they had missed out on important, and now lost, moments in their previous cesarean birth(s).  The very different experience of skin-to-skin versus standard cesarean birth had an important impact on some participants, who observed that their standard cesarean birth interfered with long-term intimacy and connection with their children. Although some thought their bonding experience was the same with children born via both delivery methods, most felt that their early moments together contributed uniquely to their attachment with their children born via skinto-skin cesarean delivery. Nearly all participants noted that breastfeeding their infant born via skin-to-skin cesarean delivery was quite different from their previous experiences, with several believing that skin-to-skin contact improved their confidence in and duration of breastfeeding.
Furthermore, participants found that touching, holding and comforting their infant offered a distraction from the surgical procedure, and some mentioned feeling less physical pain because of that distraction.
In addition to attachment and bonding, several participants observed that their infants were less stressed during skin-toskin cesarean birth than during their previous standard cesarean birth(s).

Logistic considerations
Participants recognized that skin-to-skin cesarean birth required additional resources within an already burdened health care system, and that breaking the sterile field changed standard procedures, which could potentially result in negative outcomes. They acknowledged and appreciated that offering skin-to-skin cesarean birth depended greatly on human resource power and nursing availability, and that these factors could hinder access for other women. They expressed gratitude and reiterated that skin-to-skin cesarean birth was substantially more enjoyable and that the operating room environment was much more welcoming and positive than during their standard cesarean birth(s).

Interpretation
Our results suggest that pregnant women and their partners desire a skin-to-skin cesarean birth rather than a standard cesarean birth except when separation is medically necessary, and that institutions and medical teams can support this. Delivery via skin-to-skin cesarean birth gave control over the birth experience back to women and facilitated natural mothering and infant transition to the outside world. Participants also recognized implementation barriers, including the need for additional resources and practice change.
Nonetheless, the existing literature on practice change shows that such transformations are possible. 23,46 Among 144 skin-toskin cesarean births from 2009 to 2012 at a US community hospital housing a family medicine residency program, complication rates were similar to or lower than those for cesarean deliveries without skin-to-skin contact. 23 Gouchon and colleagues 46 compared maternal and neonatal temperatures in the 2 hours after the mother returned from the operating room after skin-to-skin versus routine cesarean birth. They found that infants born via skin-to-skin cesarean delivery were not at risk for hypothermia.
In the current study, although not all participant experiences were homogeneous, the 4 predominant themes that emerged were consistent with those in previous studies exploring the role of skin-to-skin cesarean birth, which also showed positive outcomes. 8,46,47 For example, early skin-to-skin contact in the operating room and during recovery can be used as an intervention to increase the success of breastfeeding initiation in healthy infants after cesarean birth. 8,46 Healthy infants born by cesarean delivery who experienced skin-to-skin contact in the operating room had lower rates of formula supplementation in hospital (33%) than infants who experienced skin-to-skin contact within 90 minutes but not in the operating room (42%) and those who did not experience skin-to-skin contact within 90 minutes (74%). 8 The authors concluded that skin-to-skin contact after cesarean delivery is feasible and could be offered to healthy women and their infants immediately after birth. Gouchon and colleagues 46 reported that more infants born via skin-to-skin cesarean delivery than those born via routine cesarean delivery attached to the breast at 30 minutes (9 v. 4), and were breastfeeding at discharge (13 v. 11) and 3 months (11 v. 8). Women who gave birth by skin-to-skin cesarean delivery expressed high levels of satisfaction with this intervention. 46 Our results refine and add context to the existing literature on skin-to-skin cesarean birth by documenting women's experiences in their own words from their perspective. They support the WHO's recommendation of immediate skin-to-skin contact after birth regardless of delivery method unless separation is required medically. 3 Previous studies of women's experiences of skin-to-skin cesarean birth exist. 47,48 However, Frederick and colleagues 47 used a different theoretical framework than we did, had a shorter study period, included the father's experiences and was intended for a specific audience (advanced practice nurses). Stevens and colleagues' 48 results were part of a larger study, and they had a shorter study period (6 wk postpartum). In addition, our results highlight how skin-to-skin cesarean birth could be used as an intervention to facilitate breastfeeding, which is in keeping with previous studies. 8,46,48 Given that women who deliver via cesarean birth versus vaginally report a less satisfactory birth experience, 31 have higher rates of postpartum depression and are more likely to have difficulty breastfeeding, 23,31 researchers should focus on implementing skin-to-skin cesarean birth in a variety of settings and evaluating outcomes prospectively, while including women's voices, to help address these differences. In addition, the implementation of skin-to-skin cesarean birth at other hospitals may require a cultural shift in the operating room environment, changes to standard protocols, stakeholder education, positive reinforcement for staff and active support from management.

Limitations
Since our participants had experienced a previous cesarean birth, some findings may be attributable to the fact that this was not their first cesarean delivery. In addition, 4 participants (40%) had had a prior emergency cesarean birth for cephalopelvic disproportion or fetal distress, which may have affected their previous birth experience.
The women included in this study had uncomplicated singleton pregnancies with skin-to-skin cesarean birth, which may limit applicability to more traumatic cesarean deliveries.
We had a fairly homogeneous convenience sample (i.e., recruited through a large academic tertiary care centre, similar ages, married, heterosexual); therefore, the perspectives of other women, such as those from rural areas, were not included. In addition, the potential applicability of our findings to other contexts 45 is limited to similar care centres. Our sample was also small, although, within phenomenology, typical sample sizes range from 1 to 10. 49, 50 We could have conducted additional interviews; however, data saturation was reached after 10 interviews, which prompted us to stop interviewing.
There is a lack of discrepant cases; however, as described in the Methods section, we used several other strategies to increase the credibility of the data.
The study period was 3 years because of several logistic factors (interview rescheduling, other author commitments). However, participant experiences were remarkably uniform over the 3 years, which suggests that the study period window did not substantially affect the results. In addition to these logistic considerations, only 20 participants met the inclusion criteria per year.
Finally, interviews took place 1-19 months postpartum. This broad range was primarily due to logistic considerations. The first skin-to-skin cesarean delivery at Sunnybrook Health Sciences Centre was in 2013. However, this study started in 2015; therefore, the first participants were recruited up to 19 months postpartum. Once the study was underway, participants were recruited before delivery, and interviews were conducted closer to their delivery date. Given the similarity between women's responses regardless of when their interviews were conducted in relation to delivery, we are confident that recall bias was not a substantial factor.

Conclusion
This study highlights the importance of skin-to-skin cesarean birth to women. Skin-to-skin cesarean birth has the potential to improve outcomes for women and infants and increase patient satisfaction. Although widespread implementation would require practice change and a cultural shift, the current literature suggests that this is possible. In addition, our results provide a critical perspective -that of mothers -and support the transformation of traditional operating room dynamics to reflect a more patient-centred environment. They also support the WHO's recommendation of immediate skin-toskin contact between a mother and her infant whenever safely possible regardless of delivery method.