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July 2018
 What we can do more to promote 24-hour rooming-in in the private hospital

Ms. Iris Lam
Senior Nursing Officer, Lactation Consultant, Department of Obstetrics,
Hong Kong Sanatorium & Hospital

Most of the private hospitals in Hong Kong practise partial rooming-in, i.e. being short of 24 hours a day and/or not for all mothers. The practice is influenced by views and preferences of hospital policymakers, front-line healthcare professionals, mothers and families. If a change of practice is to be expected, their appreciation of the underlining issues and commitment are crucial. Education and communication are the initial steps to behavioural change. In this article, strategies for promulgating the 24-hour rooming-in practice in a private hospital are described.

What are the benefits of rooming-in for breastfeeding mothers and babies?
Step 7 of the “Ten Steps to Successful Breastfeeding” (WHO/UNICEF, 1989) stipulates that every facility providing maternity services and care for newborn infants should “practise rooming-in, i.e. allow mothers and infants to remain together 24 hours a day.”1
Benefits of rooming-in are highlighted as follows2:
  •  Is cost effective
  •  Requires minimal equipment
  • Requires no additional personnel
  • Reduces infection
  • Helps establish and maintain breastfeeding
  • Facilitates the bonding process which can positively affect breastfeeding   duration and rates
What are the benefits of rooming-in for ALL mothers and babies?
According to the consultation document “Nurturing care for early childhood development: A global framework for action and results” (WHO & UNICEF, for launch in 2018)3, “Nurturing Care” is defined as an optimal environment created by parents or carers that ensures children's good health and nutrition, safeguards their safety and security and provides them with opportunities for early learning, through responsive and emotionally supportive care and interactions. Nurturing care is essential for a child’s brain development. It lays the foundation for life-long health and well-being and builds human capital in the child that has far-reaching impact on the future generations.

“Responsive care” comprises both sensitivity and responsiveness. The former refers to parental or carers’ awareness of a young child’s cues for needs, from birth; while the latter is their ability to respond appropriately to these cues. A systematic review4 of the role of responsive parenting in child health and development shows that in developed countries, maternal responsiveness is associated with better psychosocial outcomes e.g. language acquisition, cognitive development, school achievement, social competence and self-esteem, as well as fewer behavioral and emotional problems.

Within the nurturing care model, breastfeeding and rooming-in are essential elements of the interconnected components. While breastfeeding provides optimal nutrition and ensures health of the baby, rooming-in presents an ideal setting for a mother to respond contingently to her newborn baby’s needs – hunger, comfort, etc. Experienced healthcare professionals in the maternity wards are in the best position to give guidance on breastfeeding and responsive care, especially to new mothers, as they embark on their parenting journey.

What are the benefits of rooming-in for ALL mothers and babies?
The practices of rooming-in and breastfeeding are complementary. In a private hospital, we have just started a project which aims to promote and facilitate the 24-hour rooming-in practice. The processes are described as follows:

l   Setting up a committee to promote and support breastfeeding, rooming-in and responsive care

Members of the committee include the midwife-in-charge or nurse-in-charge of the Delivery Suite, 3 Maternity Wards and the Nursery, as well as 3 International Board Certified Lactation Consultants.  The committee is responsible for formulating the strategy, drawing up and implementing the action plan, evaluating the outcome and suggesting improvement measures accordingly.  It reports to the Director of Service and Director of Nursing.

l   Designing and Conducting an evidence-based practice project

The Committee considers that, although the 24-hour rooming-in practice fits well within the “Nurturing Care” model, an evidence-based approach to clinical practice is imperative in convincing all stakeholders and ensuring optimal outcome.

A practice-based question is developed using the PICO (Population, Intervention, Comparison and Outcome) framework.5

The PICO question is:

“Does the 24-hour rooming-in practice increase client satisfaction and exclusive breastfeeding rate on discharge compared to the current rooming-in practice?”

Information is being gathered from primary research studies and systematic reviews. The evidence retrieved will be evaluated for its clinical applicability and integrated into the 24-Hour Rooming-in Practice Protocol. Content of the Protocol will include: objectives, scope and definition, responsibilities (of different parties), training and qualifications (of healthcare workers), guideline details, records and reference documents. The Protocol will be submitted to the Hospital Management for approval and implementation. 

l   Formulating a strategy and action plan for promulgating the Protocol

The Committee will then devise a strategy and action plan for promulgating the protocol. It may include developing and distributing information leaflets for families describing the evidence and practice in the hospital, holding sharing sessions and setting up game booths for mothers in antenatal education classes and healthcare workers in hospital events.

l Encouraging and providing healthcare workers with continuous education opportunities
Midwives and nurses are encouraged to learn from local and overseas experiences. They are supported by the Hospital to attend relevant overseas training programmes and urged to share the gained knowledge and experience with other colleagues.
l   Developing indicators, monitoring the process and measuring the outcome
Strategies and action plans of promulgation as well as details of the Protocol will be modified according to the results of monitoring.

The Committee firmly believes that hospital policymakers, healthcare professionals, mothers and families are obliged to work collaboratively to maximize the potential of babies. Highlighting and communicating the important roles of 24-hour rooming-in and breastfeeding in ensuring the health of babies may inspire all parties to make a wiser decision. We are now only at the beginning of the project and hope we will be able to report the outcome in the near future. 

“When you pay attention to the beginning of a story, you can change the whole story”

The Beginning of Life (Raffi Cavoukian, 2016)
Key Message:

1. Ten steps to successful breastfeeding (revised 2018). Retrieved from http://www.who.int/nutrition/bfhi/ten-steps/en/

2. Step 7. Practice rooming-in – allow mothers and infants to remain together – 24 hours a day. (2013, August 15). Retrieved from

3. WHO Consultation paper: Nurturing care for early childhood development – A global framework for action and results. (2018, March 12). Retrieved from http://www.who.int/maternal_child_adolescent/child/nurturing-care-framework-first-draft.pdf

4. Eshel N, Daelmans B, de Mello MC & Martines J. (2006). Responsive parenting: interventions and outcomes. Bulletin of the World Health Organization December 2006, 84: 991-999. http://www.who.int/bulletin/volumes/84/12/06-030163.pdf?ua=1

5. Mamedio, C., Andrucioli, C. & Roberto, M. (2007). The PICO strategy for the research question construction and evidence search. Revista Latino-Americana de Enfermagem on-line version, 15(3), 1-5. http://www.scielo.br/scielo.php?pid=S0101-11692007000300023&script=sci_arttext

Views expressed in this article are the author's and do not necessarily reflect the opinion or position of the BFHIHKA.                                           

Editor-in-Chief: Dr Shirley Leung
Editorial Team: Ms Georgiana Cheung, Ms Candice Chin, Ms Sing Chu, Ms Christine Lam, Ms Iris Lam, Ms Grace Ma

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