How rooming in helps moms and babies

Fifteen years ago, a friend of mine had her first baby at a prestigious Boston hospital. She was a resident in Ob/Gyn at the time, and a long labor ultimately ended with a c-section, and a healthy newborn boy. That evening, when she, her baby, and her husband were in their postpartum room, the nurse entered.

“It’s time to take the baby to the nursery!” she said.

My friend looked confused. “We’re planning to keep him in the room with us tonight.”

The nurse frowned. “Well, who’s going to take care of him? You just had a c-section.”

My friend gestured to her husband, who was sitting on the couch.

The nurse frowned again. “Well, you know these c-section babies can get a little junky,” she said, alluding to the mucous that babies not born vaginally sometimes cough up.

My friend replied, with emphasis, “We are going to keep our baby in our room tonight.”

The nurse shrugged. “Well, you’re a doctor. I guess if he aspirates, you can resuscitate him.” And she walked out of the room, shaking her head.

My friend used to tell this story, laughing darkly, as she recalled how she thought perhaps she should ask for the code cart to be wheeled into the room, just in case.

For the record, baby spent an uneventful night in mom’s room. But the routine separation of moms and babies – as well as other practices that have been shown to make it harder for families to get started breastfeeding – remains the default in many maternity centers in the US. Less than half of US hospitals provide routine rooming in for healthy moms and babies.

That’s bad news for babies, and it’s bad news for mothers, because these out-of-date practices make it harder for women to achieve their own breastfeeding goals. A study of nearly 2000 US mothers found that among mothers who received six of six best practices for maternity care, 97% achieved their personal goal to breastfeeding for at least 6 weeks. Among mothers who received zero of six, nearly 30% failed to achieve their personal goals.

These practices – the World Health Organization Ten Steps to Successful Breastfeeding – have been shown to be effective in a randomized controlled trial, which is the gold standard for medical evidence. In the PROBIT study, researchers randomized 31 hospitals to the Ten Steps or to continuing usual care. The study enrolled 17,046 mother-infant pairs, all of whom intended to breastfeed. Dyads who received care in a Ten Steps hospital were more likely to be exclusively breastfeeding at 3 months (43.3 vs. 6.4%) and to be breastfeeding at 12 months (19.7 vs. 11.4%). Ten Steps care has a lasting impact on breastfeeding success.

For much of the world, the Ten Steps have become the standard for maternity care. However, in the US, maternity practices continue to lag. The result is a mismatch between strong public health messaging urging moms to breastfeed, and outdated maternity practices that undermine mothers and babies.

To address this gap, Healthy People 2020 made increasing the number of infants born in Ten Steps hospitals a public health goal, and the CDC has funded a national collaborative to assist hospitals in implementing best practices. So what’s not to like? Well, a great deal, based on recent coverage of efforts to implement the Ten Steps. A recent article in the Boston Globe took issue with the move away from nurseries, calling them “long a life raft for recovering mothers,” and stated that new moms “often are surprised to learn that Massachusetts hospitals are increasingly restricting nursery access.” The account quoted 5 mothers unhappy with rooming in, before a single positive anecdote, buried 1,348 words into the 1,964-word article.

The article did not address research on rooming-in and breastfeeding, or rooming-in and sleep quality. Evidence from randomized controlled trials shows that rooming in helps moms and babies breastfeed successfully. In a study comparing infants randomized assigned to rooming-in vs. nursery care, babies who were kept in the nursery received significantly more formula and significantly less breast-milk. Moreover, evidence suggests that mothers who send their babies to the nursery do not sleep longer or better than mothers who have their babies room in. And babies sleep better in the mother’s room than in a nursery setting.

Most importantly, implementing the Ten Steps ensures that all mothers are supported to initiate and sustain breastfeeding, regardless of their age, race, or ethnicity. When breastfeeding is perceived as the domain of privileged, highly educated women, hospital staff may offer rooming-in to “the kind of women who breastfeed,” but not to “the kind of women who formula feed.” Indeed, a CDC study found that maternity facilities in zip codes with > 12.2% black residents were less likely to provide Ten Steps care than facilities with zip codes with ≤ 12.2% black residents, suggesting that disparities in care contribute to disparities in breastfeeding initiation, continuation, and, ultimately, disparities in health outcomes for mothers and babies.

Studies have found that implementation of the Ten Steps raises breastfeeding rates the most among lower-income families, and eliminates racial disparities in breastfeeding initiation. Conversely, these findings suggest that hospitals that have not implemented the Ten Steps are perpetuates disparities in breastfeeding, maternal health and child health.

However, rather than addressing these public health issues, the media coverage purports that there’s a battle being waged in hospitals between advocates for breastfeeding-über-alles and exhausted mothers denied any respite after childbirth. In fact, the guidelines for Ten Steps implementation from Baby Friendly USA support each mother’s informed decision to use the hospital nursery. The key to understanding this policy is that facilities should provide rooming-in as the standard for mother-baby care. “Standard” means that nurses will not routinely remove babies from mothers’ rooms in the evening, but will instead provide each mother with support and assistance so that she can learn how to care for her infant.

Importantly, “standard” does not mean “universal.” In my clinical practice, I regularly care for women with bipolar disorder, for whom the disruption of sleep in the early days postpartum can be catastrophic, triggering postpartum psychosis. We talk about the rationale for rooming in, and the reasons that it may not be optimal for her. And we document, in the medical record, that she will send her baby to the nursery to ensure a period of consolidated sleep immediately postpartum. That’s why Baby Friendly guidelines stipulate that at least 80% of healthy infants should be spending 23 hours a day with their mothers, unless there are medical reasons for separation. The 80% benchmark provides leeway for mothers and babies for whom rooming-in may not be optimal.

For the majority of moms, however, rooming-in has substantial advantages. In particular, having baby in the room at night is a crucial opportunity to teach families how to safely negotiate infant care, sleep and fatigue. In the absence of such guidance, tragic outcomes can occur. A troubling case series in the Journal of Perinatology documented 15 deaths and 3 near-deaths of healthy newborns sharing a sleeping surface with a parent during maternity stays between 1999 and 2013, a time period during which 61,204,386 infants were born in the US, or 2.9 events per million births. One infant was found wedged on a couch between parents; others were found limp in bed with their mothers. In each case, the author notes that there were one or more risk factors known to increase the risk of bed-sharing.

It’s tempting to simply move all the babies to the nursery at night to avoid these tragedies in the hospital. However, the postpartum stay lasts only a few days, and families need guidance for how they will manage fatigue and infant care in the days and weeks to follow. Rooming-in offers an ideal opportunity to teach families how to feed, soothe and settle infants safely, with support from experienced mother-baby providers.

The controversy in the media underscores the importance of comprehensive implementation of the Ten Steps. Appropriate prenatal education and guidance prepares families for what to expect during their maternity stay. Families need information to make an informed decision about utilizing the nursery.

With anticipatory guidance and support during the first few nights after birth, rooming-in will help the majority of moms and babies to thrive, with the flexibility to accommodate families who might need a different plan for care. Using the Ten Steps to set the standard for maternity care is good for moms and for babies.

Alison Stuebe, MD, MSc, is a maternal-fetal medicine physician and breastfeeding researcher. She is an associate professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine and Distinguished Scholar of Infant and Young Child Feeding at the Gillings School of Global Public Health. You can follow her on Twitter at @astuebe.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

What support did you receive for night-time parenting during your maternity stay? What might have made your experience better? How might we assure that each family leaves the maternity center prepared for the complexities of fatigue, sleep, and infant care?