A total of 24 mothers of preterm infants were included in the semistructured FGDs. Each FGD consisted of six participants, and data were collected until data saturation was reached. Table 1 shows the sociodemographic data of the participants.
Table 1
Description of sociodemographic data
Variables | Frequency | Total | Percentage |
Age | 18–29 30–39 40+ | 8 10 6 | 33% 42% 25% |
Educational level | Primary Secondary Tertiary | 02 18 04 | 8% 75% 17% |
Cultural group | Tswana Xhosa | 22 2 | 92% 8% |
Occupation | Employed Unemployed | 10 14 | 42% 58% |
Marital status | Single Married | 18 6 | 75% 25% |
Parity | 1st 2nd and above | 16 8 | 67% 33% |
Delivery mode | Normal vaginal delivery Cesarean section | 17 7 | 71% 29% |
Gestation at birth | Less than 30 weeks Above 30–36 weeks | 14 10 | 58% 42% |
Birth weight | Less than 1000 g Above 2000 g-2499 g | 13 11 | 54% 46% |
Table 1 shows that 44% (10) of the participants were aged 30–39 years, 33% (8) were aged 18–29 years, and 25% were aged more than 40 years (6). Approximately 8% (2) of the participants had a primary education, 75% (18) were educated up to the secondary level, and 17% (4) were graduates from the tertiary level. The majority of the participants were Tswana 92% (22), with few Xhosa-speaking people 8% (2). Among the participants chosen, 42% (10) were employed, 58% (14) were unemployed, 75% (18) were single, and only 25% (25%) were married. It was observed that 67% (16) of the sampled parents of preterm infants were primigravida mothers, whereas 33% (8) were multiparous. Among them, 71% (17) had a normal vaginal delivery, while 29% (7) had a cesarean section. A total of 58% (14) of the mothers delivered before 30 weeks gestation, 42% (10) delivered within 30 to 36 weeks gestation, 54% (13) of the preterm infants had birth weights less than 1000 g, and 46% (11) had birth weights greater than 2000 g.
Table 2
Highlights the themes and subthemes that emerged from mothers’ perceptions regarding the implementation of SSC for preterm infants
Themes | Subthemes |
1 Knowledge regarding SSC | 1.1 Physical closeness |
2 Perceived benefits of SSC | 2.1 Benefits to the baby 2.2 Benefits to the mother |
3. Challenges experienced by mother's during implementation of SSC | 3.1 Physical challenges 3.2 Psycho-social challenges 3.3 Mother's and baby's condition |
4 Support needs for mothers regarding implementation of SSC | 4.1 Provision of resources and infrastructure 4.2 Support from Healthcare professionals 4.3 Support from family sides |
In Table 2, four main themes were identified, namely, knowledge regarding SSC, perceived benefits of SSC, challenges experienced by mothers regarding the implementation of SSC and support needs regarding SSC, and nine subthemes emerged from the major identified themes. Each theme and subtheme are described in more detail and illustrated by quotations from the participants below:
Theme 1: Knowledge regarding SSC
The majority of the participants expressed a limited level of prior knowledge regarding SSC and conveyed that their understanding of the practice was acquired during their infants’ hospitalization in intensive care units through explanations provided by the nursing staff. This is captured in the following verbatim excerpts:
"I was very scared and felt uncomfortable putting my baby on chest while sleeping, 'yoh'... I felt like I was going to hurt her and I was not used in sleeping in one position thinking of turning was very stressful on me" (Participant 9).
“At the beginning, I didn’t understand, I asked myself so many questions why should I have to do this…is it necessary…but as days go by I realized the importance of it. My baby was like any other baby, just feeding and weighing 1350 g. Only the weight and I just wanted it to go up so that I could go home” (Participant 6).
“I was not familiar with SSC practices before my baby was admitted to this ward until I noticed one of the mothers doing SSC” (Participant 17).
"I had no idea that there is something like this... (referring to SSC) until one of the nurses informed me about SSC and its benefits. I began to initiate the practice with my preterm baby" (Participant 20).
1.1 Physical closeness
Physical closeness involves bonding and interaction between mothers and infants, which facilitates the infant’s later socioemotional, behavioral and cognitive development and is even related to the physical health of the child [16, 17]. Bonding and interaction between the mother and baby started at different times, and mothers shared different views. Examples of the rewarding experiences described by mothers were as follows:
“Every time when I put my baby on my chest, I see some sweats coming from both of us, which helps my baby grow. The good thing about skin-to-skin contact is that as a mother, you spend most of the time with your baby in your chest and the ability to recognize very quickly if the baby has difficulty breathing” (Participant 1).
"I felt good when I heard the heartbeat of my child during SSC on the first day of her life. I was able to bond and interact with my child, and when she is hungry, she will do that sign of touching the breast and cry after that, that is when I realized that she was hungry" (Participant 23).
Theme 2: Benefits of SSC
SSC was accepted by mothers as a safe method for improving the well-being of preterm infants. The participants highlighted that practicing SSC gave them a sense of responsibility in caring for their babies. Therefore, the following subtheme emerged:
2.1: Benefits for the Baby
Mothers are actively involved in the care of their preterm infants because of the positive outcome for the baby. One of the key factors motivating them was health education provided by health personnel on the importance of SSC, which facilitates the implementation of SSC among parents. They believed that SSC would actually make a difference for their preterm babies. The majority of the participants shared the following sentiments as the benefits of SSC to their preterm infants:
“SSC helps to prevent infection in the hospital because the mother provides proper hygiene to the baby and reduces the incidence of the baby being nursed in one incubator” (Participant 3).
“I noticed that most of the babies nursed in the incubators cries a lot because they feel like they are being abandoned. By doing SSC helps the baby cry less if I may say” (Participant 22).
Temperature regulation was more stable for preterm infants on SSC than for preterm infants not yet on SSC. This sentiment was verbalized by the mothers of preterm infants:
“Doing skin-to-skin contact is a good thing because it keeps the baby warm and keeps the temperature in a good position, but the bad thing is we kangaroo the babies for 24 hours” (Participant 8).
2.2: Benefits for mothers
Participants perceived the benefits of SSC as increasing bonding and attachments with preterm infants, facilitating breastfeeding and reducing stress and loneliness to parents. These are examples of sentiments verbalized by mothers:
SSC facilitates attachment and bonding with your child. My baby always recognizes my voice every time when I put her on my chest" (Participant 15).
“It also reduces the mother’s level of stress because as a mother you will be bonding with your preterm and able to communicate and give your baby attention”. (Participant 4)
“One thing about skin-to-skin contact is that I’m able to breastfeed on demand, and my milk is too much. My baby gets to know me better because im close to her and able to recognize my voice” (Participant 13).
Theme 3: Challenges experienced by mothers during SSC
Although there were many benefits that motivated the implementation of SSC, there were also constraints that challenged the practice. The participants perceived the following challenges that constrained the practice of SSC: physical and psychosocial challenges as well as the conditions of both parents and preterm infants. The challenges differ depending on the mother's situation, and this affects their physical, emotional and psychological well-being.
3.1 Physical challenge
Participants were dissatisfied with the equipment and the shortage of space during their practice of SSC with their preterm infants. Mothers stated that the beds were not enough to accommodate all of them in the unit, and some were forced to travel daily to the hospitals. Their emotional challenges occurred as a result of staying in uncomfortable beds longer without knowing when they were going to be discharged. The following sentiments are shared by mothers of preterm babies:
“There was not enough room to practice SSC, and most of the parents were forced to travel on a daily basis to come to the hospital” (Participant 16).
“A poor supply of equipment to use during SSC was a challenge to the parents of preterm infants. Sometimes we were told that there were no linens or gowns, and we were forced to repeat the same linens and gown for more than 3 days" (Participant 20).
The position attained by the mothers during SSC was very tiring, as the babies should be kept between the chest and abdomen. Mothers verbalized that they were expected to sit in a certain area; no sort of entertainment that they felt was boring. Participants reaffirmed this:
“I always feel pain on my spine due to the position attained while practicing skin-to-skin. When I sleep, I'm not supposed to lie of the side because I carry the baby in front of me so that attaining that position for a long time is very uncomfortable" (Participant 21).
Participants were also worried about having a long stay at the hospitals, and there was no one to look after the young people left at home. The following sentiments were expressed by the mothers:
"I'm worried with my other children left at home. I have been here for almost three weeks now and wait for my baby to gain a wait and go home" (Participant 8).
3.2 Psychosocial challenges
Participants perceived psychosocial challenges such as anxiety and stress during the practice of SSC with their preterm infants in intensive care units. Mothers shared the following:
“The day when my baby was born, I refused to hold her because she was too tingly, and I was afraid of even touching her thought I was going to hurt her. This stresses me because after birth, as a mother, you need to hold your baby on your chest and bond with her, but in my case, it was different" (Participant 24).
“I could it believe that one day I will be holding by baby like this... (Pointing SSC). When a nurse told me about SSC, I was scared that I will not be able to do it properly" (Participant 11).
"As much as I want my baby to gain weight, Im also worried with my work. I'm left behind and when I resume there would lot of pressure in order to cover for the days that I was not available" (Participant 23).
3.3 Mother's and baby's condition
Some participants reported that although they felt good doing SSC, they felt stressed with the heavy responsibility of monitoring the wellbeing of their vulnerable baby. The participants highlighted that the condition of parents and preterm infants can prevent them from engaging in SSC. Examples of sentiments shared by the parents were as follows:
"My baby was so small and was not able to breathe by herself. After birth, she was sent to the intensive care unit and put on the machine, so I could not initiate SSC immediately. I had to wait until the baby became stable" (Participant 4).
The majority of the mothers were concerned about their physical well-being. These concerns encompass sensations of fatigue, edema in the lower extremities and discomfort.
"I had complications immediately after birth, where my blood pressure was rising hence and my legs were swollen. I could not provide SSC within 24 hours to my baby" (Participant 4).
Theme 4: Support needs for parents regarding SSC with their preterm infants
The research findings revealed support needs for mothers regarding SSC implementation when the participants indicated the importance of information sharing and support from healthcare workers and their families.
4.1 Provision of resources and infrastructure
Participants shared the view that available rooms for SSC were inadequate; hence, the mothers agreed that there was a need for the creation of more rooms to meet the needs of parents. This was captured in the following verbatim excerpts:
"It was very difficult to practice SSC because the space was too small to accommodate all of us here" (Participant 15).
In addition, one of the parents indicated that due to inadequate space, she used to travel on a daily basis to come and provide care for her baby.
"I stay 20 kilometers away from the hospital; I have a daily routine of coming to the hospitals to provide care for my baby because the hospital does not have enough space to accommodate all the parents whose preterm infants were admitted to intensive care units. Only if the hospital was providing us with transport or at least accommodate all of us would it be better" (Participant 6).
A poor supply of equipment or resources needed for successful implementation of SSC affects mothers’ involvement in the care of preterm infants. The participants shared the view that their SSC practices would be enhanced if they were provided with approximate equipment. They highlighted the following:
"There are lots of things that we need to do SSC such as appropriate clothes to wear and appropriate beds since the one that we are using had no string to adjust them" (Participant 2).
"I wish if we can be provided with a conformable chair that is adjustable for SSC" (Participant 19).
"My experience would be better if nurses provided me with appropriate clothing to wear during skin-to-skin contact" (Participant 20).
4.2 Support from healthcare professionals
Some of the mothers mentioned that staff should support them when caring for their preterm babies. The findings revealed that support creates good experiences for parents who provide SSC. Healthcare professionals need to emotionally and physically support mothers of preterm infants during SSC.
“I feel like staff should support us regarding positioning preterm infants on skin for skin contact and breastfeeding” (Participant 4).
“Nurses always tell me to put my baby in SSC so that he can gain weight very quickly. They always supported me to not worry or stress too much because it will affect the health of my baby" (Participant 22).
Participants also indicated that they should be provided with pamphlets highlighting information regarding SSC, its benefits and the position of preterm infants so that they can be referred when necessary. Such information should be readily available when preterm infants are admitted to intensive care units. This is captured in the following verbatim excerpts:
"Nurses must have a training session with the mothers of preterm infants upon admission to intensive care units. We should be taught about SSC, importance, and when to initiate and stop practicing SSC" (Participant 9).
"Provision of information prior to admission of preterm infants in the neonatal unit helps mothers become familiar with skin-to-skin contact. There must be more posters pasted on the wall demonstrating how SSC should be done so that u will be easier for us to copy from there" (Participant 11).
“Health education is important, and this is want we need because some people in the community do not understand why we practice this (skin-to skin-contact)” (Participant 1).
4.3 Support from the family
Participants felt that SSC practices can be improved by greater support from their families. In other words, SSC practices should not be perceived only as the responsibility of parents; even their immediate families play a role by offering support. Mothers received encouragement from their social networks, with relatives telling them that they needed to focus on providing care for the baby’s needs. The following sentiments were shared by the parents of preterm infants:
“My family actively encourages me to provide care to my baby, including skin-to-skin practice, support breastfeeding and provide emotional support whenever needed” (Participant 7).
“I think it is important to be linked with other people with the same experience on how they cope with their preterm babies” (Participant 6).
Furthermore, one of the participants reported that their family made an effort to visit them and the babies at the hospital and constantly checked them over the phone to inquire about their well-being.
"They do contact me to inquire about our welfare and provide me with motivation on daily basis" (Participant 24).