The Effect of Prenatal Rooming-In Shared Decision-Making on Postpartum Exclusive Breastfeeding in Taiwan

doi:10.21203/rs.3.rs-3090780/v1

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Research Article

The Effect of Prenatal Rooming-In Shared Decision-Making on Postpartum Exclusive Breastfeeding in Taiwan

https://doi.org/10.21203/rs.3.rs-3090780/v1

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Background

24-hour rooming-in is a crucial policy in BFHI for promoting breastfeeding. However, Taiwan’s BFHI certification included prenatal shared decision-making (SDM) for rooming-in until 2018. Prior to this update, maternal rooming-in intentions, related factors to the prenatal SDM decision, and the impact of prenatal SDM implementation on postpartum exclusive breastfeeding were unknown.

Methods

A retrospective medical review study was conducted. Describe statistics, nonparametric tests, and generalized-estimating equation (GEE) were used.

Results

Women's comprehension of rooming-in was inadequate compared to breastfeeding. Women who were older, worked full-time, had a graduate degree, and believed that rooming-in interrupted their rest weakened their prenatal rooming-in intention. In GEE, only age (OR = 0.92, 95% CI: [0.89 − 0.97], p = 0.001), primiparity (OR = 0.50. 95% CI: [0.32, 0.78], p = 0.002), vaginal delivery (OR = 1.52, 95% CI: [1.001, 2.33], p = 0.049), and prenatal exclusive breastfeeding intention (OR = 3.33, 95% CI: [2.08, 5.33], p < .001) were related to postpartum exclusive breastfeeding, not prenatal rooming-in intention.

Conclusion

Prenatal SDM ensures autonomy for women and their families with respect to

Shared Decision-Making

Rooming-in

Breastfeeding

Prenatal Education

Breastfeeding, with its numerous health benefits for babies and women, has been vigorously promoted globally.¹ The Baby-Friendly Hospital Initiative (BFHI) was a crucial strategy for healthy facilities to promote and initiate breastfeeding.²

In response to the low rate of exclusive breastfeeding in Taiwan, which stood at only 5.4% in the 1970s, the Taiwanese government followed in the footsteps of the World Health Organization (WHO) in 2000 to boost the BFHI.³ Taiwan's efforts to promote the BFHI have achieved remarkable success. The number of accredited BFHI institutions in Taiwan has increased from 38 in 2001 to 163 in 2021, covering 73.4% of births.⁴ This achievement exceeded that of the WHO report in 2021, where only 14% of nations indicated that more than half of births occur in BFHI facilities. Moreover, Taiwan's vigorous promotion of BFHI has resulted in a substantial increase in the exclusive breastfeeding rate for infants under six months, from 46.2% in 2018 to 46.2% in 2018. 4 This rate exceeded the global average of 36% in 2019 and brings Taiwan closer to the WHO's 2025 global goal of a 50% exclusive breastfeeding rate under six months.⁵

However, advocating for the BFHI policy, particularly regarding 24-hour rooming-in, is not without controversy.^6–8 The practice of 24-hour rooming-in, which is one of the ten steps to successful breastfeeding recommended by the WHO, highlights the importance of keeping newborns with their mothers for the first 24 hours after birth. This practice aims to enhance mother-infant interaction, support demand feeding, stimulate breast milk production, and support breastfeeding.^9–11 However, 24-hour rooming-in was a "must-do" requirement in Taiwan’s BFHI accreditation before 2018, causing some postpartum women to complain of overwhelming exhaustion due to the lack of prompt nurse assistance and individualized care. ^12,13

In response to the needs of women, the Joint Commission of Taiwan (JCT), which is responsible for promotion and certification of Taiwan's healthcare policies, modified the 24-hour rooming-in practice from a "necessary" item to a "bonus" item in BFHI accreditation in 2018. This change emphasized that postpartum rooming-in implementation should be decided via the shared decision-making (SDM) process during prenatal education.¹⁴ During the antenatal SDM process, healthcare providers were expected by the JCT to inform pregnant women and their families of various rooming-in options, ensuring that they fully understood the advantages and disadvantages of each option, and then to collaborate with them to make the optimal decision for postpartum newborn care.^15,16 To promote implementation of the antenatal SDM, the JCT developed Patient Decision Aids (PDA)¹⁷ to help healthcare providers assess women's knowledge and concerns regarding rooming-in in order to detect any misunderstandings that could impede optimal decision-making.

Perhaps the BFHI has primarily focused on supporting and educating mothers about breastfeeding and encouraging practices such as immediate skin-to-skin contact and rooming-in in the past. Therefore, even though Taiwan's BFHI has been promoted for several years, there has been a lack of standardized and comprehensive investigation into the specific knowledge, concerns, and intentions of women regarding these practices. At the same time, prenatal SDM implementation raised some concerns regarding its impact on postpartum rooming-in and breastfeeding practices; therefore, this study aimed to investigate the knowledge, concerns, and intentions of women regarding rooming-in and breastfeeding, explore the related factors with women's prenatal intentions, and examine the impact of the implementation of SDM on postpartum rooming-in and breastfeeding practices.

A retrospective medical review study was conducted in a medical center in southern Taiwan after approval by the Institutional Review Board (A-ER-109-185). Medical records were reviewed for two groups of postpartum women who were ≥ 20 years of age, without intrapartum and postpartum complications (e.g., syphilis, gestational diabetes mellitus [GDM], or hypertension) that caused contraindications to rooming-in and breastfeeding practices, and delivered a live, healthy, 37-week infant during (a) January–December 2017 (before prenatal SDM implementation) and (b) January–December 2019 (after prenatal SDM implementation). The variables of interest included the characteristics of the women and their newborns, maternal knowledge, concerns, and intentions regarding rooming-in and breastfeeding, as well as the women’s postpartum implementation of rooming-in and breastfeeding practices.

Data Collection

The maternal and neonatal variables of interest were collected from the electronic medical record in a BFHI-certified medical center in southern Taiwan. Data collected included (a) maternal demographic characteristics, such as age, educational level, marital status, and employment; (b) maternal obstetric characteristics, such as parity, fetus number, and mode of delivery; (c) neonatal characteristics, such as gestational age at birth (weeks) and birth weight (grams); (d) maternal knowledge, concerns, and prenatal intentions regarding rooming-in and breastfeeding; (e) postpartum rooming-in practice during hospitalization; and (f) breastfeeding practices during hospitalization, 1-month and 2-month postpartum. The knowledge, concerns, and prenatal intentions of rooming-in and breastfeeding were extracted from the women’s responses on the two PDAs developed by the JCT in 2018. The PDA used in this study was the public version, available to medical institutions to download from the JCT website.¹⁴

The PDA of rooming-in has three subscales: knowledge, concerns, and intention for rooming-in. The knowledge scales include five items (detailed item content as shown in Table 2). Each item has a response of yes or no. The answer for Items 1, 4, and 5 is yes, and for Items 2 and 3 is no. The correct answer was worth one point, with a total score range of 0–5. The concerns scales include seven items (detailed item content as shown in Table 2). Each item was scored on a scale of 1–5, with 1 representing no concern at all and 5 representing very concerned. The options for prenatal intentions for rooming-in included three choices: 24-hour rooming-in, partial rooming-in, and separate care.

The PDA of breastfeeding consists of three subscales: knowledge, concerns, and intention for breastfeeding. The knowledge scales include six items (detailed item content as shown in Table 2). Response to each item was yes or no. The answer for Items 1–5 is yes and for Item 6 is no. Each correct answer is worth one point, with a total score ranging 0–6. The concerns scale includes six items (detailed item content as shown in Table 2). Each item scored on a scale of 1–5, with 1 representing no concern at all and 5 representing very concerned. The options for prenatal intentions of breastfeeding included three choices: breastfeeding, mixed feeding, and formula feeding.

Data Analysis

Descriptive statistics such as mean, standard deviation (SD), and proportion were used to present the participants’ characteristics and knowledge, concerns, and intention for rooming-in and breastfeeding during pregnancy as well as postpartum rooming-in and breastfeeding practice. Due to the non-normal distribution of the data, non-parametric tests for comparing the groups were used in this study. To explore the related factors with women’s rooming-in intention, the Pearson chi-square test was used to analyze the categorical variables, Fisher’s exact test was used for categorical variable with cell sizes ≤ 10, and the Kruskal-Wallis tests were used for comparing \(\ge\) two independent samples, and Dunn’s tests were a post-hoc procedure to test the differences in proportion between the two groups with Bonferroni correction (\(\alpha =0.017\)) after the significance of Kruskal-Wallis tests.

Generalized estimating equations (GEE)¹⁸ were used to explore the influence of prenatal SDM for rooming-in and breastfeeding on postpartum exclusive breastfeeding (repeated measures at three time points: during hospitalization, 1-month postpartum, and 2-month postpartum). GEE model with unstructured working correlation structure was used based on the lowest quasi-likelihood under the independent model criterion. The final model was selected by a series of univariate GEE analysis between each covariate of interest and exclusive breastfeeding when the explanatory covariate had a \(p-value\le 0.10\). Key covariates of interest included age (years), education level (coded as high school, bachelor’s degree, or graduate), prenatal rooming-in decision (coded as 24-hour rooming-in, partial rooming-in, and separate care), prenatal breastfeeding decision (coded as exclusive and mixed/formula feeding), mode of delivery (coded as normal spontaneous delivery [NSD] and C-section), parity (coded as primipara and non-primipara). Since the prenatal rooming-in decision (coded as 24-hour rooming-in, partial rooming-in and separate care) was also the main covariate of interest, it was included in the model. All analyses were performed using SAS, Version 9.4 (SAS Institute), and R software, Version 4.1.1(R Foundation for Statistical Computing, Vienna, Austria) with a significance level of \(\alpha =0.05\).

Demographic and Clinical Characteristics of the Sample

As shown in Table 1, 311 women who met the inclusion criteria in 2019 were included. The average age of them was nearly 33, and most of the women were married and held a bachelor's degree. Nearly half of them did not work full-time and were primigravida with single pregnancies and vaginal births. In addition, the average gestational age of their baby at birth was almost 39 weeks, and their average birth weight was approximately 3200 g.

Table 1

*Demographic Information of Participants by Years*
	2017 N = 621 Mean(sd)/ n(%)	2019 N = 311 Mean(sd)/ n(%)	p-value⁺
Maternal Age (year)	32.7(4.65)	33.0(4.87)	0.41
Education levels
High school or lower	91 (15.4)	50(16.1)	0.07
Bachelor’s degree	406 (68.6)	192(61.9)
Master’s degree/Doctorate	95(16.0)	68(22.0)
Marital status			0.55
Unmarried	23 (3.7)	14(4.5)
Married	597 (96.3)	296(95.5)
Employment			0.12
Full-time job	259(41.8)	146(47.1)
Part-time job	361(58.2)	164(52.9)
Primipara
No	302(48.6)	175(56.3)
Yes	319(51.4)	136(43.7)	0.03
Number of fetuses (Single)	611(98.4)	304(97.7)	0.60
Mode of delivery
NSD	353(56.8)	157(50.5)
C/S	268(43.2)	154(49.5)	0.07
Infant gestational age at birth (weeks)	38.7 (0.94)	39.0(0.94)	0.37
Infant birth weight (g)	3131.4(335)	3162.6(270)	0.11
Note. NSD = Normal Spontaneous Delivery; C/S = Caesarean section; Mixed feeding = combined breastfeeding and formula feeding; 50 missing data on 1-month feeding practice in 2017 and 47 in 2019; 30 missing on 2-month feeding practice in 2017 and 3 in 2019.
⁺ P-value for statistical tests of association between groups. Wilcoxon rank sum test was used to test continuous variables, Pearson chi-square test was used to test categorical variables, and Fisher’s exact test was used for categorical variable with cell sizes ≤ 10.

Table 2

*Knowledge, Concerns, and Prenatal Intentions for Rooming-in and Breastfeeding (N = 236)*
Knowledge of Rooming-in (Correct, n, (%))
Q1: Rooming-in facilitates the baby learning to breastfeed sooner	204 (87)
Q2: During rooming-in, my baby will sleep on the same bed as me	175 (75)
Q3: Rooming-in increases mother’s rest time	167 (71)
Q4: Separate care could increase the infant’s infection risk	138 (59)
Q5: Separate care increases the chance of the mother walking, which may cause wound pain	127 (54)
Concerns of Rooming-in (Mean ± SD)
Q1: I am able to breastfeed my baby at any time	3.79 (1.19)
Q2: I am able to nurse my baby at any time	3.82 (1.14)
Q3: I am able to learn the knowledge and skill of newborn care quickly	4.14 (1.04)
Q4: My family has more time to interact with my baby	3.72 (1.24)
Q5: I have enough time for rest	4.47 (0.83)
Q6: Rooming in is uncomfortable for the wound	4.15 (1.02)
Q7: Rooming-in disrupts my or my roommate's rest	3.91 (1.09)
Prenatal Rooming-in Intention (n, (%))
24-hour rooming-in	96 (40.7)
Partial rooming-in	34 (14.4)
Separate care	106 (44.9)
Knowledge of breastfeeding (Correct, n, (%))
Q1: Breast milk reduces many acute and chronic diseases of infants.	206 (88)
Q2: Breastfeeding decrease mother's risk of breast cancer.	178 (76)
Q3: Breastfeeding prevent postpartum hemorrhage.	166 (71)
Q4: In beginning of breastfeeding, professional and family assistance may need.	227 (97)
Q5: To avoid overfeeding, the amount of bottle feeding should be regulated by the baby.	201 (86)
Q6: Mixed feeding will not affect production of breastmilk.	80 (34)
Concerns of breastfeeding (Mean ± SD)
Q1: Breast milk provides complete nutrition for my baby	4.81 (0.44)
Q2: The influence of breastfeeding for infant’s health	4.87 (0.35)
Q3: The influence of breastfeeding for my health	4.69 (0.60)
Q4: Family’s perspectives on the method I use to feed my baby	3.30 (1.4)
Q5: Workplace support for the way I feed my baby	3.1 (1.7)
Q6: Financial considerations	3.2 (1.5)
Prenatal breastfeeding Intention (n, (%))
Exclusive breastfeeding	96 (41.0)
Mixed feeding	89 (38.0)
Formula feeding	49 (49.0)

Knowledge, Concerns, and Prenatal Intention for Rooming-In

A total of 236 women who completed the prenatal SDM process were included in the analysis after excluding questionnaires with incomplete responses. As shown in Table 2, the findings regarding rooming-in knowledge showed that the percentage of women who provided correct answers to each question varied from 54–87%. The accuracy rates for Questions 1–3 exceeded 70%, whereas the accuracy rates for Questions 4 and 5 were considerably lower, at 59% and 55%, respectively, indicating that the women were uncertain about whether separate care would increase the infant's risk of infection and their discomfort.

From the women’s responses on the concerns of rooming-in, the top three items were “I have enough time for rest”, “Rooming-in is uncomfortable for the wound”, and “I am able to learn the knowledge and skill of newborn care quickly”. Additionally, approximately 41% of women favored 24-hour rooming-in, whereas 44.9% of women preferred separate care.

Knowledge, Concerns, and Prenatal Intention for Breastfeeding

Regarding breastfeeding knowledge, the percentage of women who provided correct answers to each question varied from 34–97%. The accuracy rates for Questions 1, 4, and 5 surpassed 80%, while the accuracy rates for Questions 2 and 3 exceeded 70%. However, regarding Question 6, only 34% of the women believed that mixed feeding would affect breastmilk production.

From the women’s responses on the concerns of breastfeeding, the top three items were "Breast milk provides complete nutrition for my baby", "Breastfeeding influences infants’ health", and "Breastfeeding influences my health". Additionally, 41% of the women had the intention of exclusively breastfeeding during pregnancy (Table 2).

Factors Associated with Prenatal SDM for Rooming-In

As demonstrated in Table 3, the factors related to prenatal SDM decisions for rooming-in were tested by grouping the women based on their prenatal intention for rooming-in. The analysis revealed that women were more likely to choose partial rooming-in or separate care if they were older (p < 0.001), had master's or doctoral degrees (p = 0.02), and worked full-time (p = 0.04). The women with the intention of 24-hour rooming-in expressed higher concern about the following: (a) whether they could breastfeed at any time (Q1; p < 0.001), (b) whether they could nurse their baby any time (Q2; p < 0.001), (c) acquiring knowledge and skills regarding baby care (Q3; p < 0.001), and (d) whether they could interact with baby at any time (Q4; p < 0.001) than the other groups. Furthermore, they exhibited a higher level of concern for complete breastfeeding nutrition (Q1; p = 0.004) and workplace support for how they feed (Q5; p = 0.04) as compared to the other groups. On the other hand, women with the intention of separate care expressed higher concern that the baby would disrupt their or their roommate’s rest (Q7; p = 0.001). Additionally, women in the 24-hour rooming-in group displayed a higher intention for exclusive breastfeeding than women in the other groups (p < 0.001).

Table 3

*Comparisons of Participant Characteristics, Rooming-In and Breastfeeding Concerns, and Prenatal Breastfeeding Intention Among Different Prenatal Rooming-in Intentions (N = 236)*
	Prenatal rooming-in SDM			p-value⁺
	(1) 24-hour\(({n}=96)\)	(2) Partial (\({n}=34\))	(3) Separate (\({n}=106\))	p-value⁺
Maternal Age (year)	\(31.7\left(5.2\right)\)	\(34.1(\)4.7)	\(34.0(\)4.1)	< .0001 (1)<(2) (1)<(3)
Education levels				0.02
High school or lower	20(20.8)	5(14.7)	12(11.4)
Bachelor’s degree	65(67.7)	19(55.9)	63(60.0)
Master’s/Doctorate	11(11.5)	10(29.4)	30(28.6)
Marital status				0.22
Unmarried	3(3.1)	3(8.8)	3(2.8)
Married	93(96.9)	31(91.2)	103(97.2)
Employment				0.04
Full-time job	39(40.6)	22(64.7)	54(50.9)
Part-time/Unemployed	57(59.4)	12(35.3)	52(49.1)
Primipara				0.10
No	48(50.0)	16(47.1)	67(63.2)
Yes	48(50.0)	18(52.9)	39(36.8)
Number of fetuses				0.65
No	95(99.0)	33(97.1)	104(98.1)
Yes	1(1.0)	1(2.9)	2(1.9)
Concerns of Rooming-In
Q1	4.4(0.9)	3.9(0.8)	3.2(1.3)	< .001 (1)>(2) (1)>(3) (2)>(3)
Q2	4.4(0.9)	3.9(0.9)	3.3(1.3)	< .001 (1)>(2) (1)>(3) (2)>(3)
Q3	4.5(0.9)	3.9(1.1)	3.9(1.1)	< .001 (1)>(2) (1)>(3)
Q4	4.3(1.0)	3.6(1.0)	3.2(1.2)	< .001 (1)>(2) (1)>(3)
Q5	4.3(1.0)	4.6(0.5)	4.6(0.6)	0.07
Q6	4.0(1.2)	4.4(0.8)	4.3(0.9)	0.16
Q7	3.6(1.2)	3.9(1.0)	4.2(0.9)	< .001 (3)>(1)
Concerns of breastfeeding
Q1	4.9(0.3)	4.8(0.5)	4.7(0.5)	0.004 (1)>(3)
Q2	4.9(0.3)	4.8(0.4)	4.8(0.4)	0.083
Q3	4.7(0.5)	4.6(0.7)	4.7(0.6)	0.55
Q4	3.5(1.5)	3.2(1.2)	3.17(1.4)	0.20
Q5	3.4(1.8)	2.9(1.7)	3.0(1.7)	0.04 (1)>(2) (1)>(3)
Q6	3.3(1.6)	2.9(1.4)	3.2(1.4)	0.07
Prenatal Breastfeeding Intention (n, %)
Exclusive breastfeeding	74(77.1)	16(48.5)	32(30.5)	< 0.001
Mixed or Formula feeding	22(22.9)	17(51.5)	73(69.5)
⁺ P-value for statistical tests of association between groups. Kruskal-Wallis test was used to test continuous variables, Pearson chi-square test was used to test categorical variables, and Fisher’s exact test was used for categorical variables with cell sizes ≤ 10. Dunn’s test was used to test multiple comparisons after Kruskal-Wallis test was significant.

Figure 1 illustrates the comparison of knowledge regarding rooming-in and breastfeeding among women with different rooming-in intentions. Among the three groups, the women who intended to have 24-hour rooming-in had the highest accuracy rates for the statement that helps the baby learn to breastfeed sooner (Q1; p = 0.002). Conversely, women who intended to have separate care were more likely to recognize that rooming-in would decrease the mother's rest time (Q3; p < 0.001) as compared to the other two groups. However, there were no significant differences in breastfeeding knowledge between the groups.

The Impact of Prenatal SDM on Postpartum Rooming-in and Breastfeeding Practice

For determining the prenatal SDM's impact on postpartum rooming-in and breastfeeding, the data of 621 women in 2017 were recorded for comparison with the data of 311 women in 2019. As shown in Table 1, except that the pregnant women in 2017 were more likely to be primiparity (51.4%) than in 2019 (43.7%), there were no significant differences in other maternity and newborn characteristics between the 2 years of samples. However, Fig. 2a showed that women in 2017 were more likely than those in 2019 to implement 24-hour rooming-in during the postpartum period (42.2% vs. 25.6%, p < 0.001). Meanwhile, the exclusive breastfeeding rate during hospitalization in 2017 (45.9%) was also higher than that in 2019 (35.7%; p = 0.01), indicating that the proportion of 24-hour rooming-in and exclusive breastfeeding during hospitalization had decreased after the implementation of prenatal SDM. However, there were no differences in the exclusive breastfeeding rate at 1- and 2-month postpartum between 2017 and 2019 (Fig. 2b).

A GEE analysis was performed to determine if prenatal intentions predicted postpartum exclusive breastfeeding. As shown in Table 4, the findings revealed that prenatal exclusive breastfeeding intention and NSD were positively correlated with postpartum breastfeeding practice, whereas age and primiparity were negatively correlated. Women with the prenatal intention of exclusive breastfeeding were 3.33 times more likely to breastfeed than women without such an intention (OR = 3.33, 95% CI: [2.08, 5.33], p < .001). Additionally, women with NSD have a 52% increase in odds of postpartum exclusive breastfeeding practice as compared with women who delivered via C-section (OR = 1.52, 95% CI: [1.001, 2.33], p = 0.049). However, a 1-year increase in age decreases the odds of women choosing exclusive breastfeeding by 8% (OR = 0.92, 95% CI: [0.89 − 0.97], p = 0.001); primiparity has a 50% reduction in the odds of postpartum exclusive breastfeeding compared to non-primiparity (OR = 0.50, 95% CI: [0.32, 0.78], p = 0.002). It was worth noting that the prenatal intention of rooming-in had no significant relation to postpartum exclusive breastfeeding (p = 0.06 and p = 0.29, respectively).

Table 4

*GEE Logistic Regression Model for Predicting Postpartum Exclusive Breastfeeding (N = 236)*
Variables	Postpartum Exclusive Breastfeeding
Variables	Estimate\(\beta \left(SE\right)\)	OR	95% CI	Wald chi-square	p-value
Age	-0.08 (0.02)	0.92	[0.89, 0.97]	10.18	0.001
Education
High school degree	[Reference]
Bachelor’s degree	0.44 (0.32)	1.55	[0.83, 2.88]	1.92	0.17
Graduate degree	0.44 (0.38)	1.55	[0.74, 3.25]	1.37	0.24
Primipara
No	[Reference]
Yes	-0.69 (0.23)	0.50	[0.32, 0.78]	9.49	0.002
Mode of delivery
C-section	[Reference]
NSD	0.40 (0.22)	1.52	[1.00, 2.32]	3.85	0.0497
Prenatal rooming-in intention
24-hr rooming-in	[Reference]
Partial rooming-in	0.69 (0.37)	1.99	[0.97, 4.10]	3.49	0.06
Separate care	0.27 (0.25)	1.31	[0.80, 2.14]	1.13	0.29
Prenatal breastfeeding intention
Mixed/formula	[Reference]
Exclusive breastfeeding	1.20 (0.24)	3.33	[2.08, 5.33]	25.09	< 0.001
Note. C-section = Caesarean section; NSD = Normal Spontaneous Delivery.

This study examined women's knowledge, concerns, and intentions regarding prenatal rooming-in and breastfeeding. It also explored the factors influencing their prenatal rooming-in intentions and the impact of these intentions on postpartum rooming-in and breastfeeding practices. The study revealed that women's comprehension of rooming-in was insufficient compared to breastfeeding. The main concerns related to rooming-in included the need for rest, physical comfort, and acquiring newborn care skills. Notably, nearly 41% of the women had 24-hour rooming-in intention during pregnancy, while only 25.6% of them while only 25.6% achieved it after delivery. Factors such as older age, full-time employment, having a graduate degree, and concerns about disrupted rest weakened women's prenatal intention for rooming-in. Additionally, despite the decline in rooming-in and breastfeeding rates during hospitalization following the implementation of prenatal SDM policy, the postpartum exclusive breastfeeding rate at 1- and 2-month was unaffected. Meanwhile, the women's postpartum exclusive breastfeeding practice was positively correlated with their prenatal intention for exclusive breastfeeding and NSD, while it was negatively correlated with older age and primiparity.

The possible reason for the women's rooming-in knowledge not being as comprehensive as their understanding of breastfeeding might be that nearly 50% of the women were nulliparous in this study. This lack of prior childbirth experience might limit the imagination and comprehension of the postpartum rooming-in situation. Additionally, information about rooming-in is less commonly encountered in the lives of Taiwanese women unless they actively participate in prenatal education or search for such information. Despite the availability of subsidized prenatal education twice during prenatal checkups in Taiwan, an online survey conducted by the Birth Empowerment Alliance of Taiwan in 2023 revealed that among 2,157 pregnant women and their partners, nearly 60% have not received prenatal education.¹⁹ Furthermore, it is important to recognize that women often rely on their own efforts to seek information, which could sometimes result in misconceptions about rooming-in. This finding highlighted that Taiwan's maternity policy should emphasize the importance of prenatal education, lead the development, and subsidize the content and frequency of multi-faceted prenatal education so that women and couples will be better prepared for childbirth.

Even though the women in this study had satisfactory breastfeeding knowledge even before receiving prenatal education, the successful campaign of the Taiwanese government over the years to raise public awareness of breastfeeding benefited from using various perspectives, including social media.²⁰ However, we still found that the women felt confused about whether mixed breastfeeding affects breast milk production. This confusion may be a result of the current breastfeeding instruction guideline, which states that regular hand-expressing can be used to maintain breastfeeding when the mother is unable to breastfeed her child directly due to employment or other reasons.²¹ Meanwhile, we thought the women's responses to this question may show that they prefer a diversity of breastfeeding practices in their lives over the uniform and monotonous feeding method taught in hospitals.²²

Regarding the women’s rooming-in and breastfeeding concerns, we learned that even though the women were aware of the benefits of breastfeeding and rooming-in, they still were concerned about time for rest during postpartum rooming-in. This finding is possible because of the Chinese culture of postpartum confinement (also known as "doing the month").²³ These findings also highlighted the importance of conducting a comprehensive assessment of women's postpartum fatigue status in order to strike the ideal balance between postpartum women's physical recovery and their capacity to learn how to care for infants. ^24,25

Furthermore, we found the women's prenatal intention for rooming-in was also nearly 40%, yet only 25.6% of the mothers in this study achieved their prenatal intention for rooming-in. Even though the rooming-in rate seen in this study is the same as what a national survey done in Taiwan between 2014 and 2016 found, with rates between 20.4% and 22.2% ²⁶, it is important to encourage more efforts to help our women overcome potential barriers to achieving their prenatal goals. ^8,27

Regarding the associated factors with the women’s prenatal intention for rooming-in, we found that the women without 24-hour rooming-in intentions were older, worked full-time, had a graduate degree, and perceived or were concerned that rooming-in might interrupt their rest. The possible explanation is that pregnancy at an older age is frequently associated with education level and employment participation.²⁸ Women who become pregnant at an advanced age perceive a greater pregnancy risk and experience greater pregnancy-related anxiety, leading them to anticipate that they or their baby may require special care after giving birth and to have less confidence in their ability to care for themselves and their infants.^29–31 Moreover, the women's perception that rooming-in might interrupt their rest showed an intention for separate care. The possible explanation might be related to the belief of a mother that rooming-in or postpartum parenting are influenced by complex environmental and sociocultural factors, such as "doing-the-month" in Taiwan. ^32,33 Moreover, prior to 2018, 24-hour rooming-in was an inflexible policy in Taiwan’s BFHI hospitals, which may lead to women misunderstanding that they should take on all newborn care tasks during this vulnerable postpartum period.¹³ Therefore, it is important to ensure that women receive complete information during prenatal education regarding the situation, advantages, and disadvantages of each option for rooming-in, along with the appropriate support available for each option within a hospital environment¹¹, particularly for nulliparous women. Meanwhile, developing rooming-in care guidelines and including nurse-to-patient ratios into the BFHI accreditation standards might be necessary to ensure the women's need for rest and assistance during the early postpartum period is met. ^25,34

Finally, we found that, following prenatal SDM implementation, although the rate of rooming-in and breastfeeding during hospitalization decreased, the exclusive breastfeeding rate of 1- and 2-month was not affected, and only the prenatal breastfeeding intention, not rooming-in intention, was positively associated with their postpartum breastfeeding practice. This finding was consistent with previous studies that concluded that insufficient evidence neither supports nor refutes the effect of rooming-in practice on the duration of breastfeeding. ^35,36 Furthermore, older age and C-section decreasing the rate of postpartum breastfeeding practice might be related to postpartum fatigue, impeding the women from engaging in physically and mentally required breastfeeding activities.^7,30 Primiparity in this study reduced the likelihood of postpartum breastfeeding, which was consistent with previous research that primiparous women had a shorter duration of breastfeeding ³⁷, which might be caused by encountering more breastfeeding problems and having limited experience and community support to handle them. ^38,39

To the best of our knowledge, this is the first study in Taiwan that demonstrates women’s knowledge, concerns, and intentions during the prenatal SDM regarding rooming-in and breastfeeding practice, related factors with their prenatal SDM results, as well as the influence of the prenatal SDM for rooming-in and breastfeeding on their postpartum rooming-in and breastfeeding practice. However, several limitations should be considered. One was the retrospective design of this study and the data being obtained from medical records, leading to some missing data being unavailable (e.g., the data on 1-month breastfeeding status). Another was that the women's detailed or pragmatic perspectives on rooming-in or breastfeeding cannot be learned from medical records. Finally, due to the limited sample size and the fact that the data was collected from only one hospital that implemented prenatal SDM, these findings should be interpreted with caution.

Implications for Practice and/or Policy

Prenatal SDM is an empowered process that enables women and their families to fully participate in the decision-making process regarding their optimal postpartum care and permits healthcare providers to determine potential misconceptions for developing individual prenatal education. Therefore, in countries like Taiwan, where many births occur in BFHI hospitals, the implementation of prenatal SDM should be advocated. Also, adequate human resources should be developed as part of BFHI accreditation to create a supportive postpartum environment that meets the needs of women. Additionally, women's practice of exclusive breastfeeding was supported by prenatal exclusive breastfeeding intention and NSD, whereas it was hampered by older age and primiparity. Future efforts on continuing to advocate for exclusive breastfeeding, the optimal pregnancy age, and natural delivery, as well as tackling the needs of first-time mothers for successful postpartum exclusive breastfeeding, are recommended.

We found the women's comprehension of rooming-in was inadequate compared to breastfeeding and women require appropriate support and freedom from discomfort during rooming-in. Therefore, more efforts should direct towards advocating for prenatal SDM to ensure autonomy for women and permits healthcare providers to assess the individual need for prenatal education. Additionally, enough manpower for postpartum care, advocating for the optimal pregnancy age, and promoting natural delivery are also crucial factors that need attention.

SDM

Shared decision-making

GEE

Generalized-estimating equation

BFHI

Baby-Friendly Hospital Initiative

WHO

World Health Organization

JCT

Joint Commission of Taiwan

PDA

Patient Decision Aids

Standard deviation

NSD

Normal spontaneous delivery

C/S

Caesarean section.

Conflict of Interest Disclosures: the authors have no conflict of interest to declare.

Funding/Support: The authors received no financial support for this research

Acknowledgment: The authors thank all the participants and gratefully acknowledge Elizabeth Earl Phillips for language editing and proofreading.

Ethics approval and consent to participate

We obtained ethical approval from the Institutional Review Board of National Cheng Kung University Hospital (ID: A-ER-109-185, date: July, 2020) for this project. Due to the nature of the project involving the secondary analysis of datasets registered in NCKU Hospital and posing no more than minimal risk to participants, waivers of informed consent were granted.

Consent for publication

Not applicable.

Availability of data and materials

The datasets can be made available by contacting the corresponding author upon request.

Authors' contributions

Concept and design: Hsiao Ying Hung; Acquisition of data: Hsiao Ying Hung; Analysis and interpretation of data: Hsiao Ying Hung, Chun-Che Wen, Pei Fang Su; Drafting of the manuscript: Hsiao Ying Hung, Chun-Che Wen; Critical revision of the paper for important intellectual content: Pei Fang Su, Ying-Ju Chang; Administrative, technical, or logistic support: Ying-Ju Chang.

Authors' information

Contact details for the corresponding author are as follows: Hsiao Ying Hung, No. 1 University Road, Tainan, Taiwan, 701, R.O.C. Phone: -886-62353535 ext. 5829, Fax: -886-6-2377550, Email: [email protected].

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No competing interests reported.

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The Effect of Prenatal Rooming-In Shared Decision-Making on Postpartum Exclusive Breastfeeding in Taiwan

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Abstract

Background

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Introduction

Methods

Data Collection

Data Analysis

Results

Demographic and Clinical Characteristics of the Sample

Knowledge, Concerns, and Prenatal Intention for Rooming-In

Knowledge, Concerns, and Prenatal Intention for Breastfeeding

Factors Associated with Prenatal SDM for Rooming-In

The Impact of Prenatal SDM on Postpartum Rooming-in and Breastfeeding Practice

Discussion

Implications for Practice and/or Policy

Conclusion

Abbreviations

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References

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