Overcoming Rooming-In Barriers: A Survey on Mothers' Perspectives

Improving breastfeeding support through the implementation of the Baby-Friendly Hospital and Community Initiatives: a scoping review

BACKGROUND

Improved breastfeeding practices have the potential to save the lives of over 823,000 children under 5 years old globally every year. The Baby-Friendly Hospital Initiative (BFHI) is a global campaign by the World Health Organization and the United Nations Children's Fund, which promotes best practice to support breastfeeding in maternity services. The Baby-Friendly Community Initiative (BFCI) grew out of step 10, with a focus on community-based implementation. The aim of this scoping review is to map and examine the evidence relating to the implementation of BFHI and BFCI globally.

METHODS

This scoping review was conducted according to the Joanna Briggs Institute methodology for scoping reviews. Inclusion criteria followed the Population, Concepts, Contexts approach. All articles were screened by two reviewers, using Covidence software. Data were charted according to: country, study design, setting, study population, BFHI steps, study aim and objectives, description of intervention, summary of results, barriers and enablers to implementation, evidence gaps, and recommendations. Qualitative and quantitative descriptive analyses were undertaken.

RESULTS

A total of 278 articles were included in the review. Patterns identified were: i) national policy and health systems: effective and visible national leadership is needed, demonstrated with legislation, funding and policy; ii) hospital policy is crucial, especially in becoming breastfeeding friendly and neonatal care settings iii) implementation of specific steps; iv) the BFCI is implemented in only a few countries and government resources are needed to scale it; v) health worker breastfeeding knowledge and training needs strengthening to ensure long term changes in practice; vi) educational programmes for pregnant and postpartum women are essential for sustained exclusive breastfeeding. Evidence gaps include study design issues and need to improve the quality of breastfeeding data and to perform prevalence and longitudinal studies.

CONCLUSION

At a national level, political support for BFHI implementation supports expansion of Baby-Friendly Hospitals. Ongoing quality assurance is essential, as is systematic (re)assessment of BFHI designated hospitals. Baby Friendly Hospitals should provide breastfeeding support that favours long-term healthcare relationships across the perinatal period. These results can help to support and further enable the effective implementation of BFHI and BFCI globally.

Breastfeeding Success and Newborn Health before and during the COVID-19 Pandemic:A Single-Centre Comparative Study

INTRODUCTION

Due to the SARS-CoV-2 pandemic, adjustments in patient and visitor traffic were made in hospitals to limit viral exposure. The primary objective of our study was to compare the breastfeeding success of healthy newborns in a maternity ward during the 2020 lockdown period compared with the same period in the previous year.

MATERIAL AND METHODS

Single-center comparative study based on prospectively collected data. All neonates born alive, from a single pregnancy, and with a gestational age greater than 36 weeks were considered for this study.

RESULTS

309 infants born in 2020 and 330 born in 2019 were included. Among women who desired to exclusively breastfeed, the rate of exclusive breastfeeding at discharge from the maternity ward was higher in 2020 than in 2019 (85 vs. 79%; p = 0.078). After logistic regression analysis adjusted for potential confounders (i.e., maternal BMI, parity, mode of delivery, gestational age, and size at birth), study period remained significantly and independently associated with exclusive breastfeeding at discharge (OR [95% CI] = 1.645 [1.005; 2.694]; p = 0.046). Newborns born in 2020 were less likely to have weight loss ≥10% than those born in 2019 (OR [95% CI] = 2.596 [1.148; 5.872]; p = 0.017) but had similar need for phototherapy (p = 0.41).

CONCLUSION

The success of exclusive breastfeeding during the 2020 lockdown period was increased compared with the same period in 2019.

Barriers to Couplet Care of the Infant Requiring Additional Care: Integrative Review

BACKGROUND

Historically, once the baby was born, the mother and baby were separated shortly after birth into a postnatal ward and a baby nursery. Overtime, with advances in neonatology led to an increasing number of neonates being separated from their mothers at birth for specialised neonatal care if they required additional needs. As more research has been undertaken there is an increasing focus that mothers and babies should be kept together from birth, termed couplet care. Couplet care refers to keeping the mother and baby together. Despite this evidence, in practice, this is not happening.

AIM

to examine the barriers to nurses and midwives providing couplet care of the infant requiring additional needs in postnatal and nursery.

METHODS

A thorough literature review relies on a well-developed search strategy. This resulted in a total of 20 papers that were included in this review.

RESULTS

This review revealed five main themes or barriers to nurses and midwives providing couplet care: models of care, systems and other barriers, safety, resistance, and education.

DISCUSSION

Resistance to couplet care was discussed as being caused by feelings of lack of confidence and competence, concerns around maternal and infant safety and an under-recognition of the benefits of couplet care.

CONCLUSION

The conclusion is that there is still a paucity of research in relation to nursing and midwifery barriers to couplet care. Although this review discusses barriers to couplet care, more specific original research on what nurses and midwives themselves perceive to be the barriers to couplet care in Australia is needed. The recommendation is therefore to undertake research into this area and interview nurses and midwives to ascertain their perspectives.

A Pilot Single-Site Randomized Control Trial: Investigating the Use of Donor Milk in the Late Preterm and Term Infant in the Neonatal Intensive Care Unit

Objective : We aimed to study the use of donor milk (DM) in term and late preterm infants (LPIs) when mother’s own milk (MOM) was unavailable. We hypothesized this study would be feasible and breastfeeding attempts and the percentage of MOM (MOM%) would increase with DM without adversely affecting growth. Study Design : This was a pilot study (n=32). Infants with gestational age >34 weeks admitted to the neonatal intensive care unit were included. Infants were randomized to: the human milk (MOM+DM) or formula (MOM+F) groups. Result : Consent rate was 52%. Breastfeeding attempts increased significantly over time in the MOM+DM group compared to the MOM+F group (group p=0.41, time p =0.02, group*time p=0.01) . Growth at multiple time points was similar when the two groups were compared. Conclusion : A study randomizing term infants and LPIs to DM or formula when MOM is unavailable is feasible. DM may increase breastfeeding attempts without compromising growth.

Nurses' Perceptions of a Novel Rooming-in Program for Infants With Critical Congenital Heart Disease

BACKGROUND

The transition to home for infants who require complex care can be overwhelming for caregivers. Infants with critical congenital heart disease (CCHD) require advanced care management, so their caregivers must acquire extensive training before the infants are discharged home. Rooming-in programs have improved patient outcomes in other settings, such as the postpartum period. However, little research has examined a rooming-in program in a pediatric cardiac acute care setting.

OBJECTIVE

To describe nurses' perceptions of a novel rooming-in program implemented in a pediatric cardiac acute care unit.

METHODS

A qualitative descriptive research design was used to describe nurses' perceptions of the rooming-in program for infants with CCHD. Three focus groups were conducted with a convenience sample of 13 registered nurses who cared for infants with CCHD during the rooming-in program. Four trained independent coders performed qualitative thematic analysis.

RESULTS

Nurses provided critical insight into the rooming-in program. Three themes were identified: improved nursing and family outcomes, leading the way through collaboration, and room for improvement.

CONCLUSIONS

Infants with CCHD have complex needs, and caregivers must acquire advanced skills to adequately care for these infants. This study is the first to explore nurses' perceptions of a rooming-in program for infants with CCHD. The findings could improve rooming-in programs in the pediatric acute care setting, which can translate to better patient outcomes.

Anxiety and Psychological Flexibility in Women After Childbirth in the Rooming-in Unit during the COVID-19 Pandemic

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic has intensified perinatal anxiety disorders. Psychological flexibility (PF), considered a specific mental toughness, has not been examined with regard to its relationship with anxiety in women after childbirth. We aimed to compare levels of anxiety, PF, and pain in women depending on the mode of birth, parity, and the magnitude of risk of developing an anxiety disorder. We also investigated the association of anxiety with PF and pain.

METHODS

A total of 187 women after childbirth completed validated questionnaires for anxiety (State-Trait Anxiety Inventory, Hospital Anxiety and Depression Scale-Anxiety, Numerical Rating Scale for anxiety [NRS-A]), PF, and pain (Numerical Rating Scale for pain). Specific postpartum anxieties were assessed with a numerical scale from 0 to 10. The relationship of anxiety with PF and pain was examined. Women at low and high risk of developing anxiety disorder were compared in terms of PF, anxiety, and pain.

RESULTS

On the second postpartum day, women after cesarean birth demonstrated significantly greater anxiety on NRS-A and pain than those after vaginal birth. Primiparous women experienced significantly greater anxieties and pain compared to multiparous women. The higher the PF patients demonstrated, the less anxiety and pain they had. Patients at high risk of developing an anxiety disorder had a lower level of PF (P < .001) and higher levels of anxiety (P < .001) and pain (P < .01) than patients at low risk of developing an anxiety disorder. No difference in the anxiety of getting COVID-19 was observed between the groups (P > .05).

CONCLUSIONS

PF is an important psychological construct related to the mental and physical condition of women after childbirth. Increasing PF in women after childbirth may be considered as an important goal of preventive and intervention measures.

Validation of Chinese version of a global anesthetic recovery questionnaire: A multicenter observational trial on ObsQoR-11

BACKGROUND

The obstetric quality of recovery (ObsQoR-11) is considered one of the best patient-reported outcome measures of post-cesarean recovery. However, it has been neither validated in Chinese nor evaluated at >24 h after delivery.

METHODS

Parturients from three hospitals (n = 279) completed the Chinese ObsQoR-11 at 24 h (T₁) and 96 h (T₂) after elective cesarean delivery. Convergent validity was assessed by correlation of Chinese ObsQoR-11 with a 100-mm numerical rating scale (NRS) of general health status; discriminant validity of good recovery (NRS ≥ 70-mm); and construct validity by correlation with influential factors to post-cesarean recovery. The reliability and responsiveness were also assessed.

RESULTS

The Chinese ObsQoR-11 correlated moderately with the NRS [T₁: r = 0.38 (95% confidence interval: 0.28-0.48), p < 0.0001; T₂: r = 0.43 (95% confidence interval: 0.32-0.52), p < 0.0001] and discriminated between good and poor recovery [T₁: mean (SD) score: 64 (20) vs 49 (17), p < 0.0001; T₂: median (IQR) score: 81 (66-94) vs. 61 (53-72); p = 0.0002]; weakly correlated with gestational age, successful breastfeeding, and operation time. It was reliable (internal consistency: 0.75 (T₁) and 0.82 (T₂); split-half: 0.77 (T₁) and 0.85 (T₂); test-retest intraclass correlation coefficient r > 0.6 for each item) and responsive (Cohen effect size: 0.88; standardized response mean: 0.81).

CONCLUSION

The Chinese ObsQoR-11may be used for assessing recovery at 24 h and 96 h after cesarean delivery. However, its' cutoff value for good recovery may be lower than that of other versions.

Rooming-In and Breastfeeding Duration in First-Time Mothers in a Modern Postpartum Care Center

Uncertainty concerning the associations between rooming-in and breastfeeding duration remains at postpartum care centers. This cross-sectional study investigated the associations between the rooming-in policy and continual exclusive breastfeeding among first-time mothers at a postpartum center. Of the 160 participants, only 12.5% (n = 20) implemented full rooming-in. At 3-month follow-up, 85% (n = 17) of those individuals were exclusively breastfeeding. At the same time point, no participant practicing partial rooming-in (n = 140) was exclusively breastfeeding. The generalized estimating equation analysis indicated that full (24 h) rooming-in was statistically associated with continual exclusive breastfeeding 1 month postpartum (odds ratio (OR) = 0.90, p < 0.001) and 3 months postpartum (OR = 0.73, p < 0.001). Significant factors associated with a first-time mother's willingness to practice full rooming-in included vaginal delivery, a prenatal decision to practice breastfeeding, and undergoing prenatal classes on both rooming-in and breastfeeding. Success with continual exclusive breastfeeding in the postpartum period is dependent on full rooming-in. The findings serve as a reference for promoting exclusive breastfeeding for the first 6 months, as recommended by the World Health Organization.

Association of Caesarean delivery and breastfeeding difficulties during the delivery hospitalization: a community-based cohort of women and full-term infants in Alberta, Canada

OBJECTIVE

Breastfeeding difficulties are the most common reason for breastfeeding cessation, particularly in the early postpartum. Caesarean delivery is associated with earlier breastfeeding cessation than is the case with vaginal delivery, but differences in breastfeeding difficulties by mode of delivery have not been thoroughly examined. Our objective was to explore the association between Caesarean delivery and types of breastfeeding difficulties.

METHODS

We conducted a secondary analysis of data from a prospective cohort study of mothers who delivered full-term, singleton infants in Calgary, Alberta, Canada (N = 418). Women completed self-report questionnaires during the delivery hospitalization. Mode of delivery was defined as vaginal or Caesarean, and further classified as planned or unplanned Caesarean. Breastfeeding difficulties were measured using the Breastfeeding Experiences Scale and operationalized with binary variables for presence of various types of maternal (i.e. physical, supply, social) and infant (i.e. latch, behaviour/health) difficulties that were reported as moderate to unbearable. Multivariable logistic regression was used to estimate adjusted odds ratios (AORs) and 95% confidence intervals (CIs).

RESULTS

Overall, 37.1% of women had a Caesarean delivery and 80.9% experienced a breastfeeding difficulty during the delivery hospitalization. Of the difficulties studied, Caesarean delivery was significantly associated with low milk supply (AOR = 1.62, 95% CI = 1.16-2.28) and infant behaviour/health difficulties (AOR = 1.33, 95% CI = 1.01-1.75). The association with low milk supply persisted when examining both planned (AOR = 2.42, 95% CI = 1.19-4.92) and unplanned (AOR = 2.21, 95% CI = 1.16-4.22) Caesarean deliveries.

CONCLUSION

Mothers who deliver by Caesarean have higher odds of reporting low milk supply and infant behaviour/health difficulties than women who deliver vaginally.

Maternal awareness of breastfeeding policies in baby-friendly hospitals in Jordan

AIM

This study aims to investigate the maternal perception and awareness of Baby-Friendly Hospital Initiative (BFHI) policies.

METHOD

A descriptive, cross-sectional research design was employed. A total of 205 mothers who gave birth in two hospitals in Jordan comprised the sample for this study. A self-administered questionnaire developed from the review of literature and from an audit tool of one of the research settings was used to assess maternal perception of BFHI policies and maternal awareness of breastfeeding. Ethical approval was sought before data collection.

FINDINGS

Mothers had moderate levels of awareness of breastfeeding importance; further, most of them mentioned the provision of a policy that addresses all the steps to successful breastfeeding as a major facilitator to breastfeeding. In terms of the BFHI, mothers had a moderate level of awareness of breastfeeding initiatives and showed positive perceptions of BFHI policies.

CONCLUSION AND IMPLICATION

Improving maternal perception of BFHI policies and maternal awareness of breastfeeding has the potential to affect breastfeeding uptake and management. Future research is recommended in the areas of (1) identification of barriers to breastfeeding among Jordan mothers, (2) determination of the impact of translating maternal awareness to breastfeeding uptake, and (3) effect of infant gender and antenatal care in breastfeeding initiation and maintenance.

Associations of rooming-in with maternal postpartum bonding: the impact of mothers' pre-delivery intentions

OBJECTIVE

Full rooming-in, that is, mother and baby staying together for 24 hours per day after birth in the hospital, has been suggested as beneficial for positive maternal bonding. However, it has never been studied directly. We aimed to examine the association of full versus partial rooming-in and maternal bonding to her infant during the post-childbirth hospital stay.

STUDY DESIGN

Longitudinal questionnaire study.

SETTING

Maternity ward of a large tertiary health care center in Israel.

PARTICIPANTS

The sample consisted of postpartum women (N = 293) in a maternity ward of a tertiary health care center who were fully or partially rooming-in.

MEASUREMENTS AND FINDINGS

Questionnaires were administered at two time points, immediately after childbirth (T1; days 1-4) and 2 months postpartum (T2). The Childbirth Experience Questionnaire (CEQ), breastfeeding questions, and the Postpartum Bonding Questionnaire (PBQ) were administered at T1; the PBQ was repeated at T2. Regression analysis revealed that the rooming-in mode did not significantly predict bonding at 1-4 days postpartum. However, the rooming-in mode was a significant predictor of bonding at two months postpartum only for women who practiced the rooming-in mode they had initially planned (Beta = 0.12, p < .05), while controlling for other demographic as well as obstetric variables. Women who chose and practiced partial rooming-in manifested more bonding difficulties than those who chose and practiced full rooming-in. These distinctions in bonding were not manifested when including in the analysis women who partially rooming-in, but not in accordance with their intentions.

CONCLUSIONS

Mother-infant bonding may be optimally supported when women's pre-labor desires to participate in full rooming-in are fulfilled.

IMPLICATIONS FOR PRACTICE

Hospital staff should be aware of the mothers' intentions regarding full rooming-in requests and make sincere efforts to accommodate and support their wishes.

Promoting and Protecting Human Milk and Breastfeeding in a COVID-19 World

The global COVID-19 pandemic has put enormous stress on healthcare systems and hospital staffing. However, through all this, families will continue to become pregnant, give birth, and breastfeed. Unfortunately, care of the childbearing family has been de-prioritized during the pandemic. Additionally, many healthcare practices during the pandemic have not been positive for the childbearing family or breastfeeding. Despite recommendations from the World Health Organization to promote early, direct breastfeeding and skin to skin contact, these and other recommendations are not being followed in the clinical setting. For example, some mothers have been forced to go through labor and birth alone in some institutions whilst some hospitals have limited or no parental visitation to infants in the NICU. Furthermore, hospitals are discharging mothers and their newborns early, limiting the amount of time that families receive expert lactation care, education, and technical assistance. In addition, some hospitals have furloughed staff or transferred them to COVID-19 wards, further negatively impacting direct care for families and their newborns. We are concerned that these massive changes in the care of childbearing families will be permanently adopted. Instead, we must use the pandemic to underscore the importance of human milk and breastfeeding as lifesaving medical interventions. We challenge healthcare professionals to change the current prenatal and post-birth practice paradigms to protect lactation physiology and to ensure that all families in need receive equal access to evidence-based lactation education, care and technical assistance.

From dyad to triad: a survey on fathers' knowledge and attitudes toward breastfeeding

Fathers are known to impact breastfeeding outcomes. We aimed to explore paternal knowledge and attitude toward breastfeeding, and possible association with breastfeeding rates at discharge. In this cross-sectional study, we enrolled 200 fathers of healthy term neonates. At discharge, fathers were asked to rate their degree of agreement to 12 items on a 5-point Likert scale. A total score was obtained from their answers. Univariate binary logistic regression analysis was used to verify if the total score was predictive of exclusive breastfeeding at discharge. A multivariable logistic regression model was then used to adjust for possible confounders. ROC analysis was performed, and a Youden's total score cut-off value was determined to define total score's performance in predicting exclusive breastfeeding at discharge. Fathers showed a solid knowledge of maternal (87%) and neonatal (98%) benefits of breastfeeding, skin-to-skin (99.5%), rooming-in (79%), and responsive feeding (67.5%); conversely, only 51% knew about the recommended use of pacifiers. Fathers felt personally involved in babies' feeding in 79% of cases. An association was found between total score and exclusive breastfeeding at discharge at univariate (OR: 1.07, p = 0.04) but not at multivariable analysis (OR: 1.07, p = 0.067). ROC analysis was not statistically significant (AUC 0.58, p = 0.083).Conclusion: By using a novel instrument aimed at quantifying fathers' knowledge and overall attitude toward breastfeeding, this study underlines the importance of including fathers in the promotion of breastfeeding. Expanding the classic mother-baby dyad to a more modern mother-father-baby triad may impact breastfeeding outcomes at discharge. What is known: • Social support plays a major role in improving breastfeeding outcomes. • Fathers may greatly influence initiation and duration of breastfeeding; the more they know, the more helpful they can be. What is new: • A multidisciplinary team created a structured questionnaire aimed at quantifying fathers' knowledge and attitude toward breastfeeding. • The association between a higher questionnaire total score and exclusive breastfeeding rates at discharge highlights the importance of including fathers in the promotion of breastfeeding, as part of the breastfeeding team.

Practice Modification for Pandemics: A Model for Surge Planning in Obstetrics

This review highlights proposed pandemic-adjusted modifications in obstetric care, with discussion of risks and benefits based on available evidence. We suggest best practices for balancing community-mitigation efforts with appropriate care of obstetric patients.

The associations between insecure attachment, rooming-in, and postpartum depression: A 2 months' longitudinal study

Postpartum depression (PPD) is the most common complication of childbearing, and recent studies have attempted to examine risk factors associated with it. The main study hypothesis was that a protective situational factor at a sensitive time period (full rooming-in postpartum) would moderate the associations between insecure attachment dimensions and PPD. Three hundred twelve women, in either full or partial rooming-in, participated in a longitudinal study at the maternity ward of a tertiary healthcare center. A Demographic questionnaire and the Experiences in Close Relationships Scale were administered at 1-4 days postpartum, and the Edinburgh Postnatal Depression scale at 2 months postpartum. PPD was significantly associated with both anxious and avoidant attachment dimensions, but not with rooming-in conditions. In addition, women in partial rooming-in showed a positive correlation between insecure attachment dimensions and PPD, whereas no such correlation was found for full rooming-in women. A situational factor such as full rooming-in, which occurs at a critical time point for the mother-infant relationship, can moderate the association between maternal avoidant or anxious attachment dimensions and the mother's PPD levels. Postpartum practices, such as rooming-in, can be personalized and thus beneficial in moderating personal risk factors for PPD.

Assessment of Hospital Rooming-in Practice in Abu Dhabi, United Arab Emirates: A Cross-Sectional Multi-Center Study

The World Health Organization (WHO) recommends rooming-in to reduce infant mortality rates. Little research has been done to assess practices such as rooming-in and its relation to breastfeeding in the United Arab Emirates (UAE). The aim of this study was to examine the prevalence of rooming-in during hospital stay among mothers with infants six months old and below, in addition to other associated factors in Abu Dhabi, UAE. This study utilized a sub-sample extracted from a dataset based on a convenience sample of mothers who were recruited from governmental maternal and child health centers as well as from the community. The purpose of the original research was to evaluate infant and young children's feeding practices. A pre-tested questionnaire was used during interviews with mothers once ethical clearance was in place. Multivariable logistic regression was conducted to describe the results. The original sample included 1822 participants, of which 804 infants met the inclusion criteria. The mean age for mothers and infants was 30.3 years and 3.5 months, respectively. The rate of rooming-in during hospital stay was 97.5%. Multivariable logistic regression analysis indicated factors associated with not rooming-in were low maternal age (Adjusted Odds Ratios (AOR) = 1.15, 95% confidence interval (CI): 1.03, 1.30), low gestational age (GA) (AOR = 1.90, 95% CI: 1.52, 2.36), abnormal pre-pregnancy body mass index (BMI) (AOR = 3.77, 95 % CI: 1.22, 11.76), and delayed initiation of breastfeeding (AOR = 4.47, 95 % CI: 1.08, 18.48). In the context of the high rate of rooming-in revealed in this study, there should be a focus on those groups who do not room-in (i.e., younger women and those with babies of a younger gestational age). Rooming-in practice provides self-confidence in taking care of a baby, knowledge about breastfeeding, and stimulates early-phase lactation.