INTRODUCTION

The Baby-Friendly Hospital Initiative (BFHI) is meant to support, protect, and promote breastfeeding in facilities providing maternity and infant services¹. This initiative is a global programme that was launched in 1991 by the World Health Organization (WHO) and UNICEF as a response to an alarming decrease in breastfeeding, and was last revised April 2018. The programme aims to provide new mothers with high-quality clinical care, as well as increase the proportion of mothers who exclusively breastfeed. A practical guideline, termed the ‘Ten Steps to Successful Breastfeeding’, exists for the successful implementation of BFHI in maternity wards¹.

Numerous studies have shown that compliance to the BFHI programme is related to positive outcomes, including breastfeeding^2-4. Although mothers now spend less time at the hospital than before, the BFHI includes a period that is crucial for continued, successful breastfeeding. During their time at the hospital, mothers receive the support they will need to continue breastfeeding at home. The counselling and support that health care professionals provide during the first days is pivotal to ensuring that mothers will continue to exclusively breastfeed at home^3,5. Baby-Friendly certified hospitals provide maternity ward staff with clear instructions on how they can support breastfeeding. As a result, the maternity-ward staff at these hospitals may work differently than maternity-ward staff in non-Baby-Friendly certified hospitals¹. In this article, a non-Baby-Friendly certified hospital refers to any hospital that does not have a Baby-Friendly hospital certificate. Global statistics show that in 2017 only 10% of infants were born in Baby-Friendly certified hospitals. Only a few hospitals (16%) in Finland are Baby-Friendly certified⁶, but the BFHI Steps are used as general guidelines in every maternity hospital^7,8.

The proportion of Finnish mothers who exclusively breastfeed has decreased to alarmingly low levels, with only 1% exclusively breastfeeding at six months in 2012 (National Institute for Health and Welfare)⁹. This falls short of the global average, which now stands at 43% and has been increasing¹⁰, and lower than the averages of other Nordic countries (Sweden 14%, Norway 7%, Denmark 17%, Iceland 13%)⁶. Thus, it is important to understand the current rooming-in situation in Finland, as this knowledge is crucial to promoting exclusive breastfeeding. Rooming-in is an evidence-based practice that is used in hospitals to take care of postpartum mothers and their infants during the postpartum period¹¹. Rooming-in means that the postpartum mother and her infant are together in the same room after birth for 24 hours a day^12,13 and they are cared for as a ‘couple’¹⁴. Roomingin is divided into full rooming-in (24 h), which means that the infant stays in the mother’s room day and night, and partial rooming-in, during which the infant is in its mother’s room during the day but transferred to the nursery at night¹⁵. The practice of rooming-in is also Step 7 in the BFHI’s ‘Ten Steps to Successful Breastfeeding’ guideline, which recommends: ‘Enable mothers and their infants to remain together and to practise rooming-in throughout the day and night’¹. In this study, rooming-in refers to full rooming-in. Rooming-in is especially important for breastfeeding. It has been shown to improve breastfeeding in general¹⁶, exclusive breastfeeding at the hospital¹⁷, following discharge^15,18 and exclusive breastfeeding at 6 months¹⁹, as well as the duration of breastfeeding^13. Rooming-in makes breastfeeding easier for mothers²⁰ as it allows frequent day and night feedings^16,21. Furthermore, infants who stay in the nursery may be more likely to get fed with formula milk than rooming-in infants²². Mother-infant proximity and interactions during early postpartum period are important for breastfeeding success and milk production²³ and these interactions demand mother and infant stay together. Mothers who room-in have shown a positive attitude towards breastfeeding²⁴, and were generally satisfied with the rooming-in experience¹⁴.

Rooming-in is also important for developing a mother’s ability to respond to her infant’s needs²¹ and it facilitates a good start to mother-infant interaction^25-27. It helps mothers learn and recognise their infant’s hunger cues^28,29, and mothers gain self-confidence when they can recognise that their infant is comfortable and contented^21,30. It also facilitates early bonding and helps mother and infant ‘get to know’ each other sooner^20,31. In addition, rooming-in allows a mother to practice both caring for her infant and breastfeeding in a safe environment³². The staff can support and counsel parents at all times¹⁴, and ensure that parents grasp the importance of keeping their infant close^28,33. There is evidence that a mother’s oxytocin³⁴ and beta-endorphin levels²⁴ as well as emotional and physical wellbeing increase during rooming-in³⁵, and that it helps women embrace their new role of being a mother^29,36. Furthermore, it was shown that mothers who room-in are more sensitive towards their infant and respond to its needs lovingly and tenderly^13,20. Mothers and infants who room-in sleep better and experience less anxiety^37,38. Moreover, skin-to-skin contact, which is easy to use in rooming-in, has been shown to reduce postpartum depressive feelings and maternal physiological stress²⁹. Rooming-in increases closeness and bonding between parents and infant^17,29, strengthens a mother’s positive attachment to her infant²⁶, reduces depressive feelings and maternal physiological stress²⁹ and provides the infant with emotional security^33,36.

Rooming-in reduces the risk of neonatal complications³⁹ such as a diabetic mother’s infant hypoglycaemia, morbidity³⁹, hyperbilirubinemia¹⁶ and neonatal abstinence syndrome (NAS), as well as the rate of infant admission to the neonatal intensive care^12,40-42 and the need for pharmacotherapy^41-43. Infants cry less⁴⁴ and sleep better²² when they are close to their mother. Any separation of a mother and infant disrupts brain development, which is required for bonding. Furthermore, stress hormone levels increase when the infant is away from its mother, possibly destabilising the infant. Preterm infants gain more weight per day when rooming-in⁴⁵, and infants, who have NAS, have shorter stays in the Neonatal Intensive Care Unit (NICU)^12,40,41, which makes this approach costeffective^14,43. Rooming-in also benefits nurses, as they are entrusted with higher levels of accountability and can build their competence, which will translate into improvements in staffing flexibility and job satisfaction¹⁴.

Nevertheless, the negative sides of rooming-in must also be considered. Previous studies have shown that roomingin can interfere with a mother’s need to sleep^38,46. Mothers who room-in may suffer from fatigue, sleep deprivation and exhaustion, and this is common when a mother is responsible for caring for an unsettled infant during the night⁴⁷. Among mothers who room-in, those who gave birth through a caesarean section reported more postpartum fatigue than mothers who gave birth vaginally. Mothers who experience postpartum fatigue have difficulty performing infant-care activities, which can weaken mother-infant attachment^38,48. According to Hunter et al.³⁸, mothers who cannot determine why their infant is crying or who are unfamiliar with babysoothing skills may experience difficulties in infant care. Rooming-in also presents some risks for infants, as 58% of infant falls happen between midnight and 7 a.m., and 55% of falls occur after a family member falls asleep in a bed or chair^17,35.

This study aims to describe rooming-in (Step 7 of the BFHI) according to mothers and maternity-ward staff in Finnish maternity hospitals and to identify factors associated with the implementation of rooming-in. The study questions were: ‘What are postpartum mothers’ and maternity ward staff’s perceptions of rooming-in?’ and ‘What background factors are associated with the implementation and duration of rooming-in?’.

METHODS

Participants and data collection

Study participants comprised new mothers with their infants and the maternity-ward staff (midwives, childminders/ practical nurses, nurses and students) who cared for the mothers in maternity wards and NICUs in 8 hospitals in Finland. The hospitals were chosen by stratified random sampling, so that the study included two representative hospitals for each of the following types of hospitals defined by the National Institute for Health and Welfare: under 750 deliveries; 750–1500 deliveries; over 1500 deliveries; and university hospital⁴⁹. Two of the eight hospitals had a BFHI certificate. Each maternity hospital had a designated contact person who shared information about the study.

This research employed a cross-sectional study design. Data were collected using two different questionnaires (one for new mothers and the other for maternity-ward staff) during one week in Spring 2014. The research frame is presented in Figure 1. The study population comprised mothers (n=509) who had given birth during the data collection period and stayed in maternity wards or NICUs, as well as the maternityward staff who attended to these new mothers. Of the new mothers, 279 decided to participate in the study. However, two of the studied hospitals did not allow new mothers to answer the questionnaire. As a result, only 111 new mothers from 6 hospitals answered the questionnaire, representing a response rate of 59%. The mothers filled in the questionnaire before discharge. An unknown number of maternity-ward staff filled in a total of 1554 questionnaires concerning the 279 mother-infant pairs during the data collection period. The results concerning the maternity-ward staff questionnaire will be presented using the abbreviation f. This is because it is possible the same midwife or nurse filled in the questionnaire multiple times. For each mother-infant pair (n=279) included in the study, the maternity-ward staff member who took care of them filled in a questionnaire after every work shift, which means that three questionnaires per mother-infant pair were filled in each day.

Figure 1

Research frame

RESULTS

DISCUSSION

When the results from the mothers and maternity-ward staff included in this study are considered together, it can be stated that rooming-in was implemented to a satisfactory extent, which is comparable to an earlier study concerning Southern Finland³⁰.

Early skin-to-skin contact and initial breastfeeding after labour were found to be associated with the implementation of rooming-in. This practice enables positive bonding between the infant and mother²⁸ and, together with rooming-in, promotes mother-infant interaction⁵⁸ along with sustained, long-term exclusive breastfeeding^3,18. This study also identified an association between early skin-toskin contact following labour and a positive experience of rooming-in. An infant gets the best start to its life through the many benefits of rooming-in¹⁷, and all maternity-ward staff should understand and apply this concept in their work. One study has suggested that non-separation benefits fullterm infants and their mothers²⁸, as well as maternity-ward staff¹⁴. The maternity-ward staff unanimously felt that full rooming-in is good hospital practice. One study has found that full rooming-in increases nurses’ job satisfaction and affords them more responsibility¹⁴. A staff member’s occupation was associated with their opinion of roomingin, i.e. all midwives felt that it is good practice but staff representing other occupations did not share unanimously a positive perception. This may be because the education of these other professions does not concentrate on the benefits of breastfeeding and keeping the mother and infant together, as much as the curriculum of midwives. An evidence-based review by Jaafar et al.¹⁸ found limited support for the claim that rooming-in is better than separation after birth in terms of exclusive breastfeeding once the mother is home. The outcomes showed that rooming-in translated to a higher frequency of breastfeeding and improved rates of exclusive breastfeeding four days postpartum. Nevertheless, the research included a brief study period and acknowledged that further information about the realised benefits of rooming-in are need, which the presented study doesn’t provide.

The age and work experience of maternity-ward staff were both associated with the decision to implement roomingin. Extensive work experience underlies taking good care of mother-infant couples. Breastfeeding counselling training (20-h) seems to be a good form of education for maternityward staff as it was found to be associated with how often rooming-in is utilised. However, this education should be mandatory for all maternity-ward staff rather than just the midwives who attend to mother-infant couples, as roomingin rates were higher when staff members reported having enough time to provide breastfeeding counselling. Insufficient resources for breastfeeding counselling require wards to be well organised and to concentrate on mothers who are at risk of not breastfeeding their infant. The mode of childbirth also affected whether or not rooming-in was implemented. In this study, rooming-in was very common after normal vaginal childbirth, and most health care professionals felt that it is more appropriate after vaginal delivery than following a caesarean section. However, the separation of mother and infant after a caesarean section increases stress hormone levels in infants, and these infants also have lower betaendorphin levels than infants born through vaginal deliveries³². Following early separation, a mother’s oxytocin and prolactin levels decrease while her epinephrine levels increase, which can lead to increased stress³². Mothers who deliver through a caesarean section need more help and support during rooming-in. Maternity-ward staff are competent in providing breastfeeding assistance to mothers who had a caesarean section, especially if they have completed breastfeeding counselling training (WHO 20-h), yet it is sometimes difficult to realise that a mother needs assistance²⁴.

When full rooming-in was not used, the infant was out of the mother’s room for an average of two hours per shift. Most of the breaks lasted less than one hour and were the result of a mother’s basic needs. Infants in the nursery are more likely to receive supplementation than infants who room-in²², and this is not beneficial for the frequency of breastfeeding. The results presented in this study agree with previous findings. The most dangerous consequence of an infant receiving supplementation at the hospital is that the mother may feel that she does not have enough breast milk to feed her infant. Infants in the nursery also used a pacifier more than infants who roomed-in, but this finding was not statistically significant. The finding demonstrates that infants’ sucking needs are sated by a pacifier. Long-term exclusive breastfeeding requires a large amount of emotional support, self-efficacy and good experiences from the hospital so that mothers continue breastfeeding at home³⁰. Roomingin can be essential to a mother learning her infant’s hunger cues²⁸ and being able to immediately respond to them²¹; it also facilitates frequent feeding^16,18 and helps mothers to ‘get to know’ their infants sooner³¹. As a result, rooming-in increases exclusive breastfeeding¹⁶, makes breastfeeding easier²⁰ and builds a loving and tender relationship between infant and mother^28,29,41.

The BFHI programme aims to support, promote and protect exclusive breastfeeding in every hospital around the world⁵⁹. One surprising result in this study was that BFHIcertified hospitals did not stand out in terms of rooming-in practice. Infants in BFHI-certified hospitals were out of their rooms more than infants in non-BFHI-certified hospitals. This demonstrates that all Finnish hospitals have a similar stance regarding Step 7 of BFHI and that our birth and postpartum culture is well-aligned with the BFHI advice. In Finland all hospitals work with postpartum mothers and their infants in a quite similar way, although some of them are BFHI-certified. The culture of interactions during postpartum time are deep rooted in a country. We did, however, find that hospital size affects rooming-in utilisation in Finland, as rooming-in was used significantly more at hospitals with 750–1500 childbirths than at university hospitals. This finding may be explained by smaller hospitals having more single, family and double rooms, which would increase connectivity and thus rooming-in. The size of the room also influenced the implementation of rooming-in, as rooming-in was more common in double rooms than in smaller (single) or bigger (three to six beds) rooms. The lower rates of rooming-in in the largest rooms may have been a result of mothers feeling pressure to allow the other mothers an opportunity to sleep. One important factor to increase rooming-in may be family support for it. Nowadays fathers spend more time at wards and may care infants with mothers and so increase roomingin. Our study did not research this factor.

The results clearly demonstrated that a mother’s need to sleep and rest is a main barrier to successful rooming-in, and this problem has been highlighted by another study⁴⁶. Mothers who were primiparous, gave birth by caesarean section^38,48 and/or had a complicated and prolonged labour were more at risk to postpartum fatigue. Any mother who has undergone a difficult labour or caesarean section requires ample rest so that they can fully recover both physically and psychologically²¹. Hospitals are responsible for ensuring a mother’s wellbeing, and partial rooming-in may be a solution for mothers experiencing postpartum fatigue. It is good practice to allow a mother to leave an infant at the nursery for a short time when she is too tired or stressed, and this has been shown to make exclusive breastfeeding less demanding¹⁵ and to improve a mother’s self-efficacy³⁰. In this study, infants were out of the room for the longest periods at nights and during double shifts. This demonstrates that the studied hospitals are actively working to prevent mothers’ postpartum fatigue. Exclusive breastfeeding is also possible with partial rooming-in. Maternity-ward staff can provide breastfeeding counselling to help mothers understand the importance of exclusively breastfeeding at night and that they can manage even when they are tired. Other studies have presented contradictory results regarding complaints about rooming-in and a mother’s fatigue. Some of these studies found that mothers who practice rooming-in sleep better and have less anxiety^37,38. For this reason, maternityward staff have to be adept at recognising differences among mother-infant couples. In this way, they can help mothers decide whether rooming-in is the best choice for them and their infant. In this study, maternity-ward staff reported not having sufficient time to provide complete breastfeeding counselling, which is a concern. Under time pressure, the maternity-ward staff concentrated on counselling the essential mothers, i.e. primiparous women and mothers who had delivered via caesarean section. A possible reason for this decision is that if these mothers are supported well following the birth of their first child, then they will not need as much support during future deliveries.

Infants’ treatment in the nursery or NICU prevents the implementation of rooming-in. This could explain why not all of the mothers included in this study roomed-in with their infants. Based on evidence from previous research, this needs to change in the future. Numerous studies have shown that it is beneficial for mother and infant to be close. For this reason, hospitals should seriously consider adding family rooms to the NICU. The possibility of rooming-in in the NICU could, according to previous literature, have beneficial effects in terms of NAS treatment^12,41, prevalence of neonatal hypoglycaemia³⁹ and infections⁶⁰, as well as length of NICU stay⁴¹. Postnatal NAS can occur following the discontinuation of drug use by the infant’s mother and is a typical problem in infants born to mothers who are dependent on opioids⁴¹. Many other reasons prevented rooming-in but they occurred less often.

CONCLUSIONS

This study has shown that maternity wards in Finnish hospitals implement the practice of rooming-in to a satisfactory extent, as a substantial number of mother-infant couples are together during the postpartum period. This allows mothers and infants to get the best possible start to breastfeeding. Moreover, infants in the nursery received more formula milk than infants who roomed-in. This study supports increased implementation of the BFHI programme across Finnish hospitals, and contributes knowledge pertaining to Step 7 (rooming-in) of the initiative. Roomingin was used to a large extent with multiparous mothers and after vaginal birth. One clear challenge is how maternity-ward staff could increase rooming-in among primiparous women and mothers who delivered via caesarean section. More research is necessary before solutions to this challenge can be postulated. The current situation in Finland is promising, but there are still some problems that need to be addressed.

Our main recommendation would be that all maternity-ward staff clearly understand the importance of and their role in implementing rooming-in with the end goal being long-term, exclusive breastfeeding. A key part of this is that all staff members have completed the WHO 20-h breastfeeding counselling training, as staff who have completed this education implement rooming-in more often than staff who lack this training.