Parental experiences of providing skin-to-skin care to their newborn infant—Part 1: A qualitative systematic review

Aim To describe parental experiences of providing skin-to-skin care (SSC) to their newborn infants. Background SSC care for newborn infants has been reported to have positive physiological and psychological benefits to the infants and their parents. No systematic review regarding parental experiences has been identified. Design In this first part of a meta-study, the findings of a systematic literature review on parental experience of SSC care are presented. Data sources Four databases were searched, without year or language limitations, up until December 2013. Manual searches were performed in reference lists and in a bibliography of the topic. Review methods After a quality-appraisal process, data from the original articles were extracted and analysed using qualitative content analysis. Results The systematic and manual searches led to the inclusion of 29 original qualitative papers from nine countries, reporting experiences from 401 mothers and 94 fathers. Two themes that characterized the provision of SSC emerged: a restoring experience and an energy-draining experience. Conclusion This review has added scientific and systematic knowledge about parental experiences of providing SSC. Further research about fathers’ experiences is recommended.

Skin-to-skin care (SSC) started as kangaroo mother care (KMC) in a Colombian hospital in the late 1970s as a way to avoid cross-infections caused by a shortage of incubators in neonatal units, which forced preterm and low-birth weight infants to share incubators with each other. Another aim of KMC was to facilitate contact between mothers and their newborn babies, thus preventing infant abandonment and humanizing neonatal care (Martinez, Rey, & Marquette, 1992). During SSC, the infant, dressed in only a diaper, lies on the parent's bare chest in an upright position for shorter or longer periods. A supportive binding or a special carrying pouch helps the parent to safely hold the baby close to the chest, where it can be breastfed in the kangaroo position (World Health Organisation, 2003).
Another research topic has been the impact of SSC/ KMC on breastfeeding (Charpak et al., 2005). In infants with a low birth weight, meta-analyses demonstrated improved rates of breastfeeding and exclusive breastfeeding (Conde-Agudelo et al., 2011), while in healthy newborns breastfeeding frequency and duration were enhanced (Moore, Anderson Gene, Bergman, & Dowswell, 2012). Mothers in the SSCgroups breastfed exclusively to a greater extent at hospital discharge (Cattaneo et al., 1998;Marín Gabriel et al., 2010), a difference that in one study was lost at 1 month of age (Marín Gabriel et al., 2010) but in other lasted up to 3Á6 months (Charpak, Ruiz-Pelaez, Figueroa de, & Charpak, 2001;Hake-Brooks & Anderson, 2008).
Skin-to-skin contact has also been found to have positive effects on psychosocial factors such as parental stress and motherÁinfant attachment/bonding and also on infant development (Charpak et al., 2005). In infants with low birth weight, a meta-analysis demonstrated better motherÁinfant attachment and interaction, parental and family satisfaction, and a better home environment (Conde-Agudelo et al., 2011).
A review by Moore et al. (2012) showed that mothers who held their infant in SSC showed less anxiety and more confidence about their abilities to take care of the infant after hospital discharge. The authors conclude that SSC improved early postpartum affectionate love/touch behaviour and also affectionate touch at 1 year (Moore et al., 2012). Some researchers have shown better moods in mothers in the SSC-group (De Macedo, Cruvinel, Lukasova, & D'Antino, 2007;Morelius, Theodorsson, & Nelson, 2005) and less depression (Bigelow, Power, Maclellan-Peters, Alex, & McDonald, 2012); a randomized controlled trial (RCT) from Spain could however not show any improvement in anxiety or depression (Marín Gabriel et al., 2010). SSC decreased stress measured with salivary-cortisol (Bigelow et al., 2012;Morelius et al., 2005) or self-rating (Tallandini & Scalembra, 2006). Improved infant development and mood has been shown in the SSC-group up to 6Á12 months of age (Ohgi et al., 2002;Tessier et al., 2003).
Today, SSC/KMC is provided by parents within neonatal care worldwide, even in specialized hightech neonatal units. The degree to which SSC/KMC is practiced varies from being used around the clock (continuous KMC, C-KMC) to shorter periods during the day (intermittent KMC, I-KMC) . The use of SSC/KMC is recommended by the World Health Organization in maternity and special baby care settings (World Health Organisation, 2003). In the following, we will use the term SSC to include all provision of this method to newborn infants, regardless of gestation age of the infant, the duration of the SSC, and hospital setting.
As previously stated, meta-analyses have been conducted on physiological and psychosocial outcome (Conde-Agudelo et al., 2011;Lawn et al., 2010;McCall et al., 2010). The included studies on parental behaviour and mood were performed with parametric outcome measures such as self-rating or observational scales. Several studies using qualitative methodology have also explored experiences and perceptions of parents who participated in SSC, but to our knowledge no qualitative systematic review has been published. This literature review synthesizes findings from 29 original research papers from different countries and clinical settings.

Aim
The aim with the qualitative systematic review was to describe parental experiences of providing SSC to their newborn infants.

Design
The present qualitative systematic literature review was the first step of a meta-study guided by the methodology described by Paterson et al. (2001). The three first steps in the meta-study: a) formulating a research question, b) selecting and appraising primary research, and c) meta-data analysis are presented in this paper as a foundation for the metasynthesis and interpretation resulting in a tentative theory (Paterson et al., 2001), which are presented in part 2. These two papers are the result of a Swedish-Brazilian research collaboration.

Research question
The research question was: ''How do parents of newborn infants experience performing SSC?'' We decided to include original qualitative research about the experiences of all types of skin-to-skin intervention reported by mothers and fathers of newborn infants, irrespective of gestational age and hospital setting.
Search methods Systematic search. In order to ensure an adequate scientific level, we limited the inclusion criteria to published original papers and doctoral dissertations. No language or publication year limitations were set. After screening subject headings (CINAHL), A. Anderzén-Carlsson et al. -terms (PubMed) and key words from some relevant manually identified articles, the search-terms Kangaroo, Kangaroo Care, Skin-to-skin, Parents, Parental attitudes, Parental behaviour, Infant care, Mother, Father and ParentÁchild relations were used in different combinations. The searches were performed in March 2009. Since the initial searches revealed extensive published research on this topic from Latin-America, further database searches were performed in SciElo and LILACS, two databases specialized in Latin-American research. To ensure actuality, the literature searches were repeated in June 2010 and in November 2013, using the same methodology ( Figure 1).

Mesh
Manual search. Manual searches were also performed in a bibliography compiled by Susan Ludington (personal communication), in reference lists and based on personal knowledge.

Search outcome
Together the systematic searches resulted in 328 original papers of which 24 were duplicates. The manual search added a further 16 articles to be appraised for possible inclusion. Thus, the first set of articles for title and abstract review comprised 320 papers.

Title and abstract review
As it was not possible to restrict the search to qualitative papers, the titles, and when available, the abstracts were scrutinized by each of the authors individually in order to identify papers that met the inclusion criteria. A large number of papers used quantitative methodology or focused on other aspects of newborn care, such as experiences of the neonatal intensive care unit (NICU) environment or breastfeeding, and were thus excluded from further analysis.

Quality appraisal
Sixty-eight of the 320 papers were retained for the intended full text review. However, two of them could not be retrieved in full text, leaving 66 for further evaluation.
The authors read and appraised the full text of the 66 articles and compared their decisions pertaining to inclusion/exclusion. Each paper was scrutinized by 2Á3 researchers in Sweden and Brazil (the articles in English and Portuguese, respectively) and, in one case, by a Japanese researcher (one article in Japanese).
All papers considered for inclusion were appraised by means of the Primary Research Appraisal Form presented by Paterson et al. (2001). This tool, developed from Burns' (1989) statements about methodological congruence, was used to obtain structured information from and assess the methodological quality of the papers. The appraisal form is divided into sections describing the theoretical underpinnings, role and credentials of researchers, as well as research design, method, and major findings. Thereafter, the quality of the research and findings was appraised and a decision was made about whether or not to include the paper. To enable discussion and decision-making within the research group, the required information from all articles was translated into English. As a result of the quality appraisal, 26 papers were excluded due to methodological reasons (being anecdotal or not containing a qualitative analysis of parental experiences) or for being beyond the scope of this review. Finally, an additional 11 papers were excluded because of flaws in the description of aims or analyses or because it was impossible to distinguish parental experiences from other findings ( Table I).
Most of the papers in this group were case studies including 1Á2 cases and presenting the findings mainly in the form of quotations from parents. Finally 29 original papers were included, reflecting SSC in Brazil, Denmark, England, Japan, Norway, South Africa, Sweden, Uganda and he United States (Table II). Most of the participants in the included studies were mothers (n 0401) while 94 fathers where included.

Data extraction
Data related to parental experiences were retrieved from quotations in the original papers, as well as from the findings sections in these papers. All relevant data were extracted and copied into a ''Citations and findings extract template,'' which in the further process was regarded as the primary data for analysis.

Meta-data analysis
The meta-data analysis synthesizes data from the text of the included literature. The same data analysis techniques that can be used in primary research are also applicable to meta-data-analysis (Paterson et al., 2001). Thus, qualitative content analysis (Graneheim & Lundman, 2004) was chosen as a strategy for the meta-data analysis. The analysis was performed by means of the nVivo 8.0 (QSR International, Doncaster, Victoria, Australia) software. All findings from the ''Citations and findings extract template'' were imported into the software database and were coded and categorized by three researchers. Based on similarity of content, the codes were collapsed into descriptive manifest categories. Thereafter, sub-themes revealing an interpretative level of content were searched for. Finally, two themes were identified, based on the content of the 5 sub-themes and 19 categories (Table III). During the entire process, discussions were held between the research groups in Sweden and Brazil.

A restorative experience
The common latent content of the categories in this theme are the positive and restorative components of the parental experience of providing SSC. Feeling good is the dominant part found in the literature, but the theme also includes experiences of doing good for the infant and a sense of becoming unified as a family.
One woman described experiencing a strange feeling when her infant was placed on her chest immediately after delivery. The mother felt sweaty and wet, yet appreciated the experience (Finigan & Davies, 2004). Furthermore, mothers described a sense of calm and peace (Dalbye et al., 2011) and feeling relaxed when providing SSC to their infant (Affonso, Wahlberg, & Persson, 1989;Heinemann, Hellstrom-Westas, & Hedberg Nyqvist, 2013;Neu, 2004;Roller, 2005). In a neonatal setting as well as in delivery care fascination was described by the infant's movements and competence in exploring the world by looking around (Affonso et al., 1989;Finigan & Davies, 2004). Parents were found to be delighted at being able to watch their premature infant's development, which should have been taking place in utero (Leonard & Mayers, 2008) and to sense the little heart beating (Neves et al., 2010). The immediate sense of love and compassion for the infant was accompanied by reduced guilt, anguish De Moura & Araú jo, 2005), fear, and rejection (De Moura & Araú jo, 2005).
Relieving emotional suffering. SSC enabled the mothers to acknowledge their innermost feelings, elaborate on the experience of giving birth to a premature infant and find meaning in the situation (Affonso et al., 1989). To see the infant's strength, eased the mother's pain caused by the infant's   Both parents felt an immediate and intense connection with their adoptive daughter and that they began to ''know'' her while providing KMC.
Case study without a description of data collection or analysis.

Price, 2005, United Kingdom
To improve awareness of breastfeeding and the importance of skin-to-skin contact between mother and baby at birth.
M: Action research with semi-structured audio-taped interviews.
P: Midwives and 8 mothers in a maternity unit. I: Skin-to-skin contact at birth.
The mothers' relationships with their babies were enhanced. The SSC helped the mothers to endure painful experiences and felt natural. Appreciated being able to use own body to keep the baby warm.
The results from the interviews with the mothers were sparsely analysed and reported.
A rewarding experience. Mothers described SSC as a reward (Duarte & de Sena, 2004;Finigan & Davies, 2004) that they would not like to forego (Finigan & Davies, 2004). SSC was also characterized as meeting mothers' need for affection (De Moura & Araú jo, 2005) and providing them with well-being  and energy (Dalbye et al., 2011).
A natural instinct. Parents revealed that SSC was a natural instinct (Affonso et al., 1989;Byaruhanga et al., 2008;Caetano et al., 2005;Finigan & Davies, 2004;Neu, 1999). In one study, being natural was related to a desire to protect and do everything possible for the infant (Caetano et al., 2005), also expressed as the right thing to do from the infant's perspective (Finigan & Davies, 2004).
A learning experience. Mothers who provided SSC described that it taught them how to be a mother (Johnson, 2007) and made them accustomed to handling their infant (Affonso et al., 1993;Campos et al., 2008;Eleutério et al., 2008;Furlan et al., 2003;Lamy et al., 2011;Martins & Dos Santos, 2008;Toma, 2003;Toma, Venancio, & Andretto, 2007) and to breastfeed (Braga et al., 2008;Toma et al., 2007). Experience in taking care of the infant prepared the mothers to assume full responsibility after discharge from the hospital (Affonso et al., 1989(Affonso et al., , 1993Furlan et al., 2003;Lamy et al., 2011;Leonard & Mayers, 2008). Leonard and Mayers' (2008) study described that fathers wanted to be instructed in kangaroo care by the mothers, not by professionals. One father said that since he never played with dolls as a child, this was a new and pleasant learning experience for him (Helth & Jarden, 2013).
Finding a role. Mothers felt the need to take responsibility for something when their infant was hospitalized due to prematurity and SSC fulfilled this need (Affonso et al., 1993;Johnson, 2007;Roller, 2005). Johnson (2007), Leonard and Mayers (2008), and Campos et al. (2008) found that SSC allowed parents to experience being a part of the infant's care process. Other authors found that SSC facilitated mothers to assume a mother role (Affonso et al., 1989(Affonso et al., , 1993 M: Observations, questionnaires, interviews. P: 5 motherÁbaby dyads.
All mothers followed the prescribed activities and the period spent on the Program seems to have been used as a reflective moment in their lives.
Mixed methods. Difficulty to distinguish experiences from other findings.
Swinth, 2000, USA To illustrate how one mother was assisted in sharing KMC with her newborn triplets. M: Case study, the mother was cared for in a randomized control study in a KMC setting and expressed concern about being unable to spread her love between the three babies as well as her four older children.
P: Mother and her 3 baby boys, GA 35 w, BW 1336 g, 1736 g and 1882 g. I: 3 skin-to-skin sessions over 2 d from day 6 immediately after caregiving and bottle-feeding.
The shared kangaroo care relieved fears about being unable to love all three infants as well as four older children.
Case study without a description of the data collection and analysis. Author, year of publication, country of study Aim of the study Design, data collection, and analysis Population studied (P) Exposure to SSC (E) Major findings Affonso et al., 1989, Sweden To identify and compare themes based on the reactions of two groups of mothers, using a cognitive adaptation framework.
Exploratory, descriptive design. Individual semi-structured interviews on the unit during and after the infant's care. Deductive content analysis using the attachment framework.
P: Sub-group of 33 healthy mothers, mean age 26.5 y (16Á37 y). Total study: 66 mothers providing or not providing SSC. 33 infants, mean GA 31.1 w (26Á28 w). E: When taken out of the incubator, the infants were healthy, stable, and between 1 and 30 d.
According to the framework of the cognitive adaptation theory, the mothers searched for meaning and described a sense of mastery as well as selfenhancement No data on infants provided.
Increased bonding between mother and baby, reduction of the infant's separation from the family, increased competence and confidence on the part of the parents even before discharge, improved relationship between the mother and the rest of the family, within the family, and with the team taking care of the baby.  The lived experience consists of one central category: Weighing the risks and benefits between staying with the child in the kangaroo method or with the family, including three phenomena: 1) unexpected evolution and outcome in pregnancy, 2) coping with the prematurity of the child, 3) living with the decision and the experience together with the child. Campos et al., 2008, Brazil To explore the mothers' perceptions of KMC.
Descriptive study with qualitative approach. Semi-structured interviews.
No data on infants provided.
Strengthening of the bond between mother and newborn. Mothers recognize and appreciate the physical benefits for the infant and the opportunity to learn how to take care of a premature baby.  KMC is an opportunity to recover the disbanded unit, favouring transition from a pregnant woman to a mother. KMC is a form of process that involves women's bodies and emotions, strengthens their bond with the infant, and is perceived as rewarding. Eleutério et al., 2008, Brazil To explore the perceptions of mothers who experienced KMC during hospitalization in the KMC infirmary.
Semi-structured interviews. Content analysis.
P: 9 mothers in a KMC unit.
No data on infants provided.
The mothers considered the Kangaroo method an opportunity for learning how to care for their babies and that bonding is relevant and helps in the baby's recovery.

Finigan & Davies, 2004, England
To explore women's lived experiences of SSC with their baby immediately after birth.
To investigate the experiences from the women's own perspective and establish whether or not this is a mother-friendly approach.
Audio diaries from birth up to 28th day post-partum.
In-depth interviews. Thematic analysis. P: 6 mothers (21Á36 y), 5 multigravidas. E: SSC within 30 m of the birth and maintained for at least 1 h.  The thematic analysis resulted in two categories: 1) learning how to be a kangaroo mother, 2) living as a kangaroo mother.  Four main themes, which were reduced to one essential structure of knowing: mothers were prevented from knowing or getting to know their preterm newborn. Only one theme concerned the aim of our study; kangaroo care and also some parts of the theme Reassurance Toma, 2003, Brazil To increase understanding of the influence of hospital conditions and family organization on KMC practice.
Qualitative descriptive design. Interviews based on a guide. P: 14 young mothers (10 first time) and 7 fathers. No data on infants provided.
The opportunity for effective parent participation from the beginning of life supports the creation and strengthening of the relationship and makes taking care of Mayers, 2008;Neu, 1999) and increased their confidence (Affonso et al., 1993;Furlan et al., 2003). Providing the infant with milk meant being part of the beneficial process of the child's growth and development (Leonard & Mayers, 2008). De Moura and Araú jo (2005) argued that SSC had an impact on mothers' social identity, as motherhood in Brazil is highly valued and essential in the construction of a woman's social identity. SSC also helped the women's partners in starting to assume the father role (Affonso et al., 1993 (Johnson, 2007), although they also valued the care given to the infant by the nurses .
Feeling of control. SSC gave mothers and fathers a sense of control (Affonso et al., 1993;Helth & Jarden, 2013;Roller, 2005 Toma et al., 2007), which in turn made them more relaxed Furlan et al., 2003). They were able to follow the infant's development (Furlan et al., 2003;Neves et al., 2010). The SSC reduced the mothers' fear related to the infant and the NICU-environment. As a consequence, mothers visited the infant more frequently and experienced the technical equipment as a valuable tool for monitoring the infant's health in her own absence (Affonso et al., 1989). SSC reassured mothers that the infant's ability to breastfeed was improving (Affonso et al., 1989;Campos et al., 2008;Neves et al., 2010;Toma, 2003).
A supportive environment. The restorative aspect of SSC embraced experiences of an enabling environment leading to a more positive experience of SSC as well as an increased well-being in the parents; they felt good about the experience. This was expressed as a positive and encouraging attitude from the professionals that made it easier for the parents to provide SSC Leonard & Mayers, 2008;Neu, 1999;Neves et al., 2010). In addition, practical assistance when providing SSC was experienced as valuable (Blomqvist & Nyqvist, 2010;Campos et al., 2008;Lamy et al., 2011;Neu, 2004). Mothers described the nurses as care-providers for both themselves and the infant Neu, 2004). When providing SSC, mothers experienced themselves as VIPs on the ward (Blomqvist, Frolund, Rubertsson, & Nyqvist, 2013;Campos et al., 2008). They appreciated when nurses and technical staff were kind, quiet, and understanding  and reported that they relied on the staff (Lamy et al., 2011). Accessibility was described as essential for successful SSC (Neves et al., 2010) and, furthermore, a comfortable environment was also important (Affonso et al., 1989;Blomqvist et al., 2013;Furlan et al., 2003;Heinemann et al., 2013). Good food, clean surroundings, and the possibility to watch TV while staying with their infant was also highlighted (Furlan et al., 2003). In one study, support from other mothers who had been in the same situation was stated to be of great value (Lamy et al., 2011). From a Swedish study even the government was seen as supportive, providing social benefits that allowed the parents to take a leave from work to be with their newborn at the NICU (Blomqvist et al., 2013).
Mainly in Brazilian studies (Arivabene & Tyrrell, 2010;Caetano et al., 2005;Furlan et al., 2003;Lamy et al., 2011;Martins & Dos Santos, 2008;Toma, 2003;Toma et al., 2007), but also in a study from Sweden (Blomqvist et al., 2012), the importance of family support was highlighted. Mothers described how visits from the father made SSC easier (Caetano et al., 2005;Martins & Dos Santos, 2008) and that fathers helped in the home while they were at the hospital providing SSC (Toma et al., 2007). Furthermore, it was revealed that if the father could manage to be present at the hospital, they could share SSC, which made the mother feel at ease (Toma, 2003). Mothers also valued support from other relatives (Arivabene & Tyrrell, 2010;Lamy et al., 2011;Martins & Dos Santos, 2008;Toma, 2003;Toma et al., 2007). One study reported that the local church provided support by organizing volunteers to help older children with their homework and assisting in the home, which made SSC in the hospital easier for the mother. Support from neighbours was also mentioned as positive (Arivabene & Tyrrell, 2010), while two studies reported the importance of religious belief (Arivabene & Tyrrell, 2010;Lamy et al., 2011).
Doing good A way of knowing and understanding. SSC was one means of becoming familiar with the infant by noticing and interpreting her/his signs (Affonso et al., 1989(Affonso et al., , 1993Blomqvist et al., 2013;Eleutério et al., 2008;Johnson, 2007;Neu, 2004;Neves et al., 2010). Mothers experienced that they became even better at this than the nurses and technical equipment. More specifically, they reported that they became accustomed to the infant's breathing (Affonso et al., 1989;Leonard & Mayers, 2008;Neves et al., 2010) and knew what to do if it diverged from the normal pattern (Affonso et al., 1989). Furthermore, they learned to recognize signs of hunger and became more aware of the infant's body temperature and sleep pattern (Neves et al., 2010). SSC reduced the parents' sense of their infants being fragile and thus their anxiety about caring for her/him (Affonso et al., 1993;Leonard & Mayers, 2008;Toma, 2003). As mothers and fathers got to know the infant by means of SSC, they also learned to recognize her/his competence (Blomqvist et al., 2012;Furlan et al., 2003;Johnson, 2007;Lamy et al., 2011) and sensed her/his strength of life (Nakajima, 2002).
Mothers emphasized the importance for the infant of knowing that she was there for her/him (Lamy et al., 2011;Neu, 1999). SSC allowed the infant to smell the mother and to be held in a different way than by the nurses. SSC was regarded as transferring affection (Arivabene & Tyrrell, 2010;Campos et al., 2008;Eleutério et al., 2008), strength, courage, and hope to the infant (Leonard & Mayers, 2008). Furthermore, in one study SSC was described as important for infants other than one's own baby, as it freed incubators, which other infants might require (Braga et al., 2008).
Although good for the infant, providing SSC was experienced as difficult when the infant underwent blood tests (Arivabene & Tyrrell, 2010). Nevertheless, mothers accepted the need for some sacrifices, as they recognized the benefits of SSC for their infant (Braga et al., 2008;Campos et al., 2008;Duarte & de Sena, 2004;De Moura & Araú jo, 2005). Apart from the family at home, their own career was sacrificed by their dedication to SSC (Arivabene & Tyrrell, 2010). Fathers expressed that it was natural to support the mothers in providing SSC by accepting that they paid less attention to their normal duties at home, a sacrifice considered natural because of the infant (Furlan et al., 2003).
Intimate togetherness. It was reported that the SSC strengthened the sense of being a family (Braga et al., 2008;Dalbye et al., 2011;Finigan & Davies, 2004;Furlan et al., 2003;Heinemann et al., 2013;Johnson, 2007). Providing SSC was described as involving both parents, as they took it in turns (Toma, 2003). It was also seen as a family issue where the mother taught the father (Leonard & Mayers, 2008) or the parents supported each other in providing SSC and were both available to the infant (Caetano et al., 2005;Dalbye et al., 2011). Mothers described that during SSC their entire focus was on the infant (Finigan & Davies, 2004;Johnson, 2007). SSC was reported to provide a better bonding experience than breastfeeding (Roller, 2005) or any other kind of holding (Johnson, 2007).
Finally, the infant became familiar with the mother thanks to the SSC Lamy et al., 2011). The infant's attachment was described in terms of being able to smell (Affonso et al., 1989;Furlan et al., 2003;Lamy et al., 2011;Leonard & Mayers, 2008;Neves et al., 2010;Roller, 2005) and touch the mother, thereby knowing that she/he was with her/his mother (Affonso et al., 1989;Furlan et al., 2003;Lamy et al., 2011;Leonard & Mayers, 2008;Roller, 2005). Once this contact had been established, mothers stated that the infant wanted to continue SSC with the parents, instead of lying alone in a cot or pram (Arivabene & Tyrrell, 2010).

An energy-draining experience
The SSC was not only described in terms of being a restorative experience; it was also considered as energy-draining. The parents at times felt exposed when providing SSC and they were afraid of hurting others, primarily the infant, but also older children and family.
Feeling exposed Environment as an obstacle. There were many reasons why the environment was experienced as an obstacle. First, lack of autonomy was described; Mothers of full-term babies who provided SSC on the delivery ward experienced that their autonomy were not respected when they did not want to practise SSC but the midwife wanted them to do so (Byaruhanga et al., 2008).
Mothers expressed that it was difficult to practise SSC at the hospital, but easier at home where there were no spectators (Leonard & Mayers, 2008).
Some reported unease at having to expose their body on the ward (De Moura & Araú jo, 2005;Neu, 1999). Fathers described feeling critically assessed by staff when providing SSC, something that made them feel incompetent (Blomqvist et al., 2012;Helth & Jarden, 2013;Leonard & Mayers, 2008). The absence of a private bathroom was also negative in terms of privacy (Eleutério et al., 2008).
Inadequate privacy and lack of control (Blomqvist et al., 2013;Heinemann et al., 2013;Neu, 1999) were described as factors that made parents discontinue SSC. Other negative aspects were a physical environment with noise, hectic activity (Blomqvist et al., 2013) and sterility, as well as lack of support (Blomqvist & Nyqvist, 2010;Heinemann et al., 2013;Neu, 2004). Lack of information about the practical application of SSC was described as an obstacle (Blomqvist & Nyqvist, 2010;Dalbye et al., 2011), while technical equipment distracted or frightened parents and made them (Blomqvist & Nyqvist, 2010;Blomqvist et al., 2013;Neu, 2004), and thereby their infant, tense (Neu, 2004). When mothers felt that it was cold on the ward, they found it harder to take a break from SSC (Neves et al., 2010), or to initiate SSC, not wanting to undress the infant (Dalbye et al., 2011).
There were negative statements regarding family rooms, such as that they were too small and the beds uncomfortable (Blomqvist & Nyqvist, 2010;Blomqvist et al., 2012). Mothers requested furniture that would facilitate SSC, such as comfortable beds and armchairs, as they found it tiring having to remain in a sitting position all day (Braga et al., 2008;Furlan et al., 2003). Others wished for some form of activities to distract them, as they missed their home (Eleutério et al., 2008).
In two of the Latin-American studies, parents highlighted that travels to and from the hospital to provide SSC was a financial burden (Furlan et al., 2003;Toma et al., 2007) and in one study it was reported that the distance between the hospital and the family home made it more difficult to provide SSC on a daily basis (Neves et al., 2010). Negative remarks from relatives sometimes were seen as an obstacle to SSC (Blomqvist et al., 2012;Dalbye et al., 2011).
A physical and emotional burden. Parents described suffering from backache (Duarte & de Sena, 2004;Leonard & Mayers, 2008;Toma et al., 2007), being bored or tired, and experiencing anxiety when providing SSC in a KMC ward. Sleeping with the baby was experienced as difficult, because of the mother being woken up during the night (Leonard & Mayers, 2008;Neves et al., 2010), the responsibility A. Anderzén-Carlsson et al.
Providing SSC for many hours each day was also described as hindering other activities (Blomqvist et al., 2013;Duarte & de Sena, 2004;Leonard & Mayers, 2008;De Moura & Araú jo, 2005;Neves et al., 2010). It was so difficult to visit the toilet or find time to eat that at times these needs were put aside, instead of taking a break from SSC (Neves et al., 2010). Providing SSC on a 24-h basis also had an impact on the mothers' relationships outside the hospital and they experienced loneliness (Leonard & Mayers, 2008). Some mothers expressed frustration, feeling imprisoned at the hospital (Toma, 2003;Toma et al., 2007), and thereby in need of support from relatives to take care of their other children (Lamy et al., 2011;Toma, 2003;Toma et al., 2007). SSC was also experienced as tiring (Affonso et al., 1993;Blomqvist et al., 2012;Braga et al., 2008;Furlan et al., 2003;Toma et al., 2007) and stressful (Martins & Dos Santos, 2008).
The first attempt with SSC made some mothers tense and uncomfortable (Roller, 2005). Some felt more at ease and less stressed when holding the infant wrapped in a blanket, (Neu, 1999) and yet others experienced that the staff treated them as if they had no idea what they were doing (Neu, 2004). Another reason for feeling uncomfortable with SSC was that the mothers were afraid of bonding with their fragile infant (Nakajima, 2002). Although SSC facilitated breastfeeding in many cases, breastfeeding difficulties have been reported (Toma et al., 2007).
However, although experienced as uncomfortable at times, mothers considered SSC necessary (Braga et al., 2008;Duarte & de Sena, 2004;Neves et al., 2010) and some described it in terms of sacrificing their own needs for the infant's wellbeing and safety (Duarte & de Sena, 2004;Leonard & Mayers, 2008;Neves et al., 2010).
Incongruence between wishes and demands. Parents described that their own wishes were not always in line with the demands placed on them, by themselves or by others. They may have wanted to do more SSC than allowed to (Caetano et al., 2005;Finigan & Davies, 2004;Heinemann et al., 2013;Helth & Jarden, 2013;Johnson, 2007;Neu, 1999) or take a break, but felt obliged to continue (Blomqvist & Nyqvist, 2010;Blomqvist et al., 2013;Furlan et al., 2003;Martins & Dos Santos, 2008;Toma et al., 2007). In some cases, staff explicitly stressed the needs of and benefits to the infants (Arivabene & Tyrrell, 2010;Blomqvist & Nyqvist, 2010;Neu, 2004 #3589;Toma, 2003). In two studies, it was stated that mothers were allowed to take a break if feeling emotionally exhausted (Affonso et al., 1993;Blomqvist & Nyqvist, 2010). This was appreciated and in one of these studies it was reported that, on returning, the mothers were more motivated to continue SSC (Affonso et al., 1993). Fathers stated that they preferred providing SSC at home after the infant had been discharged, instead of at the hospital, where they felt exposed to spectators (Leonard & Mayers, 2008). On the contrary, fathers who were prevented from providing SSC for organizational reasons were frustrated and helpless, as they could not interact with their infant. One father described observing another father providing SSC until he was told to stop by staff members, an approach he considered too harsh (Leonard & Mayers, 2008).
In studies from a maternity ward setting, both parents expressed that they wanted to provide SSC, not just the mother (Finigan & Davies, 2004). However, some mothers did not like having their naked infant skin-to-skin after delivery, but wanted her/him washed and dressed beforehand (Byaruhanga et al., 2008).
Uncertainty about the purpose of and own skill in providing SSC. At times, parents did not understand the purpose of SSC (Byaruhanga et al., 2008;Leonard & Mayers, 2008;Toma, 2003), and in the delivery setting it was in some cases believed to be a trick to distract mothers who had to be sutured after a vaginal delivery (Byaruhanga et al., 2008). The parents were also uncertain about their own skill in providing SSC, which was especially obvious at the start of SSC (Leonard & Mayers, 2008;Martins & Dos Santos, 2008;Neu, 1999), but also in general (Eleutério et al., 2008;Martins & Dos Santos, 2008). They therefore expressed a need for guidance about how to hold the infant (Affonso et al., 1989;Johnson, 2007;Martins & Dos Santos, 2008). Toma (2003) highlighted the importance of supportive staff for successful SSC. Fathers thought that the mothers were superior in providing SSC and that the infant would not feel as comfortable with them. This assumption was based on a belief that the infant preferred the mother's smell (milk) and that the male body was not as suitable for SSC in a traditional position. However, some stated that they found alternative ways of providing SSC (Leonard & Mayers, 2008).
When an early SSC session ended with the infant being negatively affected, it created fear of providing more SSC (Neu, 1999). Worry about hurting the infant decreased over time as the parents continued to provide SSC (Johnson, 2007;Martins & Dos Santos, 2008), although some parents discontinued SSC due to feeling very anxious (Neu, 1999). Parents not only feared physically hurting the infant but also disturbing her/him emotionally (Leonard & Mayers, 2008). Mothers described that at times their baby was uncomfortable with SSC (Neu, 1999;Toma et al., 2007).
Feeling insufficient towards the family. Mothers and fathers described feeling that they were neglecting the infant when staying with their family instead of providing SSC in the hospital (Caetano et al., 2005). They also reported feeling inadequate in meeting the needs of their other children (Arivabene & Tyrrell, 2010;Blomqvist & Nyqvist, 2010;Blomqvist et al., 2012Blomqvist et al., 2013Caetano et al., 2005;Campos et al., 2008;Dalbye et al., 2011;Duarte & de Sena, 2004;Lamy et al., 2011;Leonard & Mayers, 2008;Toma et al., 2007), husband (Arivabene & Tyrrell, 2010;Caetano et al., 2005;Campos et al., 2008;Duarte & de Sena, 2004;Johnson, 2007;Leonard & Mayers, 2008;Martins & Dos Santos, 2008), or parents (Duarte & de Sena, 2004). When reflecting on the tension between the infant and her/ his older siblings, the mothers compared the children's need of them; the infant did not know them (Toma, 2003) and was taken care of by professionals in the hospital (Caetano et al., 2005), while older children knew and missed them (Caetano et al., 2005;Toma, 2003). However, mothers felt that the infant needed them more than the older children, who were healthy and thereby had less need (Caetano et al., 2005;Campos et al., 2008;Lamy et al., 2011). One mother described a feeling of tension when having to decide which twin needed SSC the most as there was only room for one in the ''bag'' used when providing SSC. Similar to the reasoning about older siblings, the mother opted to care for the smallest infant, as he/she needed more attention (Neves et al., 2010).
Parents reported that a consequence of the mother's SSC was that it changed family routines (Arivabene & Tyrrell, 2010;Caetano et al., 2005;Furlan et al., 2003;Martins & Dos Santos, 2008;Toma et al., 2007). At times the fathers had to assume responsibility for older children (Blomqvist et al., 2012;Caetano et al., 2005) or household tasks that they usually did not do (Toma et al., 2007). Fathers also had to engage help at home in order to stay with the mother and support her when providing SSC (Caetano et al., 2005) or expressed an accepting attitude that the mother spent less time on household chores (Furlan et al., 2003). However, being away from the family, knowing that her husband and children had to struggle at home, in combination with worries about the infant, influenced SSC (Arivabene & Tyrrell, 2010).

Discussion
The findings offer a broad spectrum of nuances of parental experiences of providing SSC to their newborn infant, which have not been summarized before.
It is possible to trace some similarities between our findings and the results from studies conducted with parametric outcome scales. Below we will try to illuminate some issues where the qualitative findings can be seen as converging and complementing some of the previous results based on quantitative methodology (Heale & Forbes, 2013). In the majority of the included studies in this systematic review, experiences of being important for the infant were found. Such experiences were, for example, increased temperature control and increased growth, similar to results found by Charpak et al. (2005) and shown in the meta-analysis by Conde-Agudelo et al. (2011). Parents also experienced that by providing SSC they could influence the duration of hospital stay, converging the findings from the meta-analysis (Conde-Agudelo et al., 2011). However, the findings in this present systematic review complement the findings of a shorter duration in hospital by offering an understanding of the mothers' expereince of this phenomena; By taking care of the infant, the mothers experienced themselves as prepared to assume full responsibility after discharge from the hospital. Together, the findings of shorter duration of hospital stay and the readiness to assume a full responsibility at discharge offers a more complete picture and understanding of the mothers' situation, than just one of these perspectives.
The fact that there are similarities in the parental experiences of their own importance for the infants improvement, and in results describing the effect of SSC is interesting. Is it so, that the parents are informed by the professionals about previos benefitial research results, and adapt to them? This seems reasonable, as it was described that in some cases, staff explicitly stressed the needs of and benefits to the infants in order to motivate parents to perform SSC.
In infants with a low birth weight, meta-analyses demonstrated improved rates of breastfeeding and exclusive breastfeeding (Conde-Agudelo et al., 2011). Furthermore, mothers in the SSC-groups breastfed exclusively to a greater extent at hospital discharge (Cattaneo et al., 1998;Marín Gabriel et al., 2010). SSC was also in this systematic review seen as a method to facilitating breastfeeding. To succeed with breastfeeding was experienced as leading to an improved self-esteem, and by providing the infant with milk it meant being part of the beneficial process of the child's growth and development. However, although the SSC was described as facilitating breastfeeding, breastfeeding difficulties were reported in one study.
Another pattern in the results was that the parents expressed that SSC was related to bonding and attachment between the parent and the infant. Also, in studies with quantitative methodology SSC was found to have positive effects on mother-infant attachment/bonding (Charpak et al., 2005;Conde-Agudelo et al., 2011). A feeling of becoming a family was identified in the findings. This can be seen as related to the results in a the previously mentioned meta-analysis were mothers providing SSC to infants with low birth weight, demonstrated better family satisfaction (Conde-Agudelo et al., 2011).
Previously positive effects on psychosocial factors such as parental stress have been reported (Charpak et al., 2005). A review by Moore et al. (2012) showed that mothers who provided SSC showed less anxiety and more confidence about their abilities to take care of the infant after hospital discharge. These findings have similarities with what here have been synthesized as SSC relieving emotional suffering, feeling needed and that SSC was experienced as offering some degree of control over the situation. Furthermore, the current results point at SSC being experienced as a learning experience, which leads to an improved self-esteem.
The results also highlighted some problems experienced by the parents in a more obvious way than previously shown in individual papers. Besides reporting practical and emotional obstacles to providing SSC it was also evident that many parents were afraid of hurting their infant and uncertain of their own capacity. This knowledge is important when planning for and performing SSC-programs in health care settings.
Today, SSC is provided by parents within neonatal care worldwide, although the degree to which SSC is practiced varies (Kymre, 2014;Nyqvist et al., 2010;Olsson et al., 2012). Meta-analyses have been conducted on physiological and psychosocial outcomes (Conde-Agudelo et al., 2011;Lawn et al., 2010;McCall et al., 2010). Nevertheless, a qualitative systematic review can add other perspectives (Noyes & Hayter, 2013). For example, this review highlights the importance of support for a positive experience of providing SSC, as well as offers information of what can hamper such an experience. Such knowledge is important to take into consideration in order to further develop the SSC worldwide. Reviews have the potential to be of importance on policy and practice (Noyes & Hayter, 2013). Authorities assessing health care interventions from a broad perspective, covering medical, economic, ethical, and social aspects argue for the combination of health technology assessment (HTA) and synthesis of qualitative studies to provide decision-makers with the best possible evidence-based foundation (SBU, 2014). Mixed methods or triangulation of methodology can provide a more comprehensive picture than a single methodology (Heale & Forbes, 2013). Reviews of qualitative evidence are also regarded as important to develop theories and hypothesis (Noyes & Hayter, 2013).
The major strength of this literature review is that findings published in languages other than English have been included. This means covering large geographical and cultural areas, as well as most published research up until 2013. Two or three researchers participated in all steps (selection, appraisal, data extraction, and analysis) of this meta-research study. The use of nVivo8 facilitated the analysis phase by providing a good overview of the data, thus enabling the process of identifying patterns (c.f. Polit & Beck, 2012). Other authors have identified disadvantages using software programs, such as too early closure of the analysis, or the inflexibility resulting in inability to testing the reliability of categorizations (Krippendorff, 2004). However, we did not experience these disadvantages. To enable analysis all material had to be translated into English, leading to a risk of loss of nuances in the interpretation of the findings. One limitation is the uneven distribution between mothers and fathers in the included original papers. We have in our results section tried to deal with this by being faithful and write mothers when the findings relate to mothers, fathers when they relate to fathers, and parents in situations where the gender of the parent have not been clearly defined, and when the results actually refers to parents. We suggest further research on the gender-specific roles of parents in providing SSC.
Parental experiences of skin-to-skin care*Part 1 Int J Qualitative Stud Health Well-being 2014, 9: 24906 -http://dx.doi.org/10.3402/qhw.v9.24906 Another possible limitation is that three of the original papers included report the experiences from delivery care settings while the rest reflect experiences from neonatal or KMC-settings. It was judged as best to include those three articles as they met the inclusion criteria in the searches. The findings from these papers do not render any exclusive categories; they just add some nuances in the overall identified pattern.

Conclusion
This qualitative literature review has added scientific and systematic knowledge about parental experiences of providing SSC to their newborn infant. It constitutes a valuable complement to previous metaanalyses on physiological and psychosocial outcomes on mothers and infants, and it offers a more detailed picture than the previous meta-analyses on the topic. From an evidence-based perspective, this systematic review shows that mothers and fathers who provide SSC can experience the SSC as restorative, as well as energy-draining. However, as the mothers' experiences previously have dominated research of the parental experiences of SSC, studies about the fathers' experiences of providing SSC should be undertaken, in various geographical and cultural settings. Such knowledge could lead to a better understanding of the fathers' situation within neonatal care.