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Separate care for new mother and infant versus rooming-in for increasing the duration of breastfeeding

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Authors

Sharifah Halimah Jaafar1, Kim Seng Lee2, Jacqueline J Ho3

Background - Methods - Results - Characteristics of Included Studies - References - Data Tables & Graphs


1Department of Obstetrics and Gynaecology, KPJ Ipoh Specialist Hospital, Ipoh, Malaysia [top]
2Department of Pediatrics, Fatimah Hospital, Ipoh, Malaysia [top]
3Department of Paediatrics, Penang Medical College, Penang, Malaysia [top]

Citation example: Jaafar SH, Lee KS, Ho JJ. Separate care for new mother and infant versus rooming-in for increasing the duration of breastfeeding. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD006641. DOI: 10.1002/14651858.CD006641.pub2.

This is a Cochrane Pregnancy and Childbirth Group External Web Site Policy systematic review.

Contact person

Sharifah Halimah Jaafar

Department of Obstetrics and Gynaecology
KPJ Ipoh Specialist Hospital
Raja Dihilir Street
30450 Ipoh
Perak
Malaysia

E-mail: drshj65@gmail.com
E-mail 2: drsharifah65@gmail.com

Dates

Assessed as Up-to-date: 23 July 2012
Date of Search: 30 June 2012
Next Stage Expected: 31 October 2013
Protocol First Published: Issue 3, 2007
Review First Published: Issue 9, 2012
Last Citation Issue: Issue 9, 2012

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History

Date / Event Description
01 April 2008
Amended

Converted to new review format.

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Abstract

Background

Separate care for a new mother and infant may affect the duration of breastfeeding, breastfeeding behaviour and may have an adverse effect on neonatal and maternal outcomes.

Objectives

To assess the effect of mother-infant separation versus rooming-in on the duration of breastfeeding (exclusive and total duration of breastfeeding).

Search methods

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2012).

Selection criteria

Randomised or quasi-randomised controlled trials (RCTs) investigating the effect of separate mother-infant care versus rooming-in after hospital birth or at home on the duration of breastfeeding, proportion of breastfeeding at six months and adverse neonatal and maternal outcomes.

Data collection and analysis

Two review authors independently assessed the studies for inclusion and assessed trial quality. Two review authors extracted data. Data were checked for accuracy.

Main results

There were 23 reports from 19 potential trials identified. After assessment, one trial (involving 176 women) met our inclusion criteria.

One trial reported an overall median duration of any breastfeeding of four months. Exclusive breastfeeding before discharge from hospital (at day four postpartum) was significantly lower in the separate care group compared with the rooming-in group (risk ratio (RR) 0.58; 95% CI 0.42 to 0.81; one trial, 141 women). 

Authors' conclusions

We found little evidence to support or refute the practice of mother-infant separation versus rooming-in. Therefore, we see no reason to practise it. We recommend a well designed RCT to investigate full mother-infant rooming-in versus partial rooming-in or separate care on all of the primary and secondary outcomes suggested.

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Plain language summary

Separate care for new mother and infant versus rooming in for increasing duration of breastfeeding

In the early part of the 20th century when hospitals became the place of birth for babies the practice of providing separate care for the infant and mother became established in industrialised countries. Babies were kept securely in a separate nursery. The infant is brought to the mother’s room for breastfeeding, on demand or during scheduled feeding times, or the baby’s mother walks to the nursery to breastfeed her infant. Breast-milk production begins immediately after parturition. Its regulation is controlled by the mother’s physical and psychological condition, the frequency of breastfeeding, effective infant's suckling, the stimulus of the sight and sound of the baby's cry, and self-confidence and contact with the baby.

Separating infants from their mothers after birth can reduce the frequency of breastfeeding and the amount of breast milk a mother produces. Whereas infants staying together with the mother throughout their hospital stay would have more frequent suckling of the breast and thus promote closeness and bonding. Many hospitals have now started to keep the mother and baby in the same room, particularly since the advent of the WHO/UNICEF Baby Friendly Hospital Initiative in 1991. This systematic review aimed to establish from randomised controlled trials whether separate care or rooming in after birth resulted in a longer duration of exclusive breastfeeding once they had returned home.

The review included one trial (involving 176 women), which looked at exclusive breastfeeding four days after birth and found this was less in the separate care group. It did not report all the important primary and secondary outcomes pre-specified in our review protocol. Thus, we found little evidence to support or refute the practice of mother-infant separation post delivery, therefore, we see no reason to practice it.

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Background

Description of the condition

Separating a mother from her baby or keeping them together in the same room after birth are both traditional practices. However, in the early part of 20th century, when hospitals became the predominant sites for birth in industrialised countries, separation of mothers and babies became widely practised. Newborns were cared for in hospital nurseries and mothers in postnatal wards. Babies were brought to their mothers for feeding, but otherwise remained in the hospital nursery until discharge. More recently some hospitals have begun the practise of keeping the mother and infant together in the same room to promote breastfeeding.

Description of the intervention

Separate care was introduced to hospital practice for both maternal and infant benefits. Placing the infant in the hospital nursery after birth allows the mother to sleep and rest. While she is recuperating, she can either walk to the nursery whenever she feels ready, as frequently as she wishes or she can request the infant to be brought to her room for demand breastfeeding. Alternatively all babies are brought from the nursery to their mothers at fixed intervals usually of about three or four hours (Hiller 2006). In order to maintain optimal breast-milk production, the mother may continue to stimulate her breasts in between the breastfeeding by either milking the breasts by hand massage or using the mechanical pump to emulate the infant's suckling (Hill 1996). In addition, there is also a security concern for infants when other patients and visitors have access to them, especially in hospitals with open maternity wards. In the hospital nursery, there is tighter security as access to the infants is strictly limited to mothers and midwives and in some hospitals even mothers are not allowed into the nursery. One of the reasons for the practice of separate care was the belief that it would protect babies from infection. However, serious outbreaks of nursery infection were reported leading to a proposal that keeping the mother and baby together might prevent infections (Hiller 2006).

Keeping mother and infant together has been termed rooming-in. It is defined by World Health Organization (WHO 1998), as the hospital practice where postnatal mothers with normal infants (including those born by caesarean section) stay together in the same room 24 hours a day, from the time they arrive in their room after delivery. They remain together until discharge unless there is a specific medical indication which warrants separation. During rooming-in the infant is placed close to the mother either by bed-sharing, an attached side-car crib or by her bedside in a stand-alone cot.

Separate care may also be partial, for example it could be practised during the night and rooming-in during the day or rooming-in during the hospitalisation and separate care at home after discharge or vice versa.

How the intervention might work

Labour is a stressful event for both the mother and infant. Most mothers, especially primigravidas, those mothers who have had caesarean section or prolonged and complicated labour, require adequate rest after childbirth in order to recover physically and psychologically. Increased levels of stress hormones during childbirth have been shown to affect the onset of breast-milk production leading to early breastfeeding failure (Chen 1998), and this could be potentially reduced by separate care.

On the other hand, separate care might be harmful because the process of breast-milk production begins immediately after parturition with secretion of copious breast milk in the first 24 to 36 hours, progressing to mature breast milk by 72 hours postpartum (Neville 2001). The regulation of breast-milk production during this period is controlled by multiple factors including the maternal physical and psychological condition, the frequency of breastfeeding and effective infant suckling (Knight 1998; Neville 1988). Previous research had also demonstrated that higher breastfeeding frequency during the early days of puerperium contributes to optimal milk production (Daly 1993), higher milk volume (Wilde 1995), and adequate milk supply for a longer period (Hill 2005) and thus, likely to result in an increase in the duration of breastfeeding. On the contrary, lack or delay in breast stimulation in the first few days after delivery may result in suboptimal breast-milk production, low milk supply and early cessation of breastfeeding (Neville 1988). A previous randomised study suggested that breast-milk expression by hand or pump is associated with less milk production (Becker 2008) and has a higher risk of mastitis (Potter 2005) when compared to direct breastfeeding. It is also suggested in one study that mother-infant separation in the early days of puerperium negatively affects the breast-milk production and reduces the duration of breastfeeding (Elander 1984), but there are other studies that show maternal intention and interest in breastfeeding is the most important determining factor that influences the success of breastfeeding (Forster 2006; Lee 2007).

Placing the infant in close proximity to the mother enables the mother to respond in a timely way whenever her infant shows sign of readiness to feed. Uninhibited mother-infant interaction and close contact promotes bonding, encourages demand breastfeeding and results in more efficient infant suckling that are all essential in the regulation of breast-milk production. Observational studies suggest that rooming-in is associated with higher breastfeeding frequency (Yamauchi 1990), higher rate of exclusive breastfeeding (Buranasin 1991) and longer duration of breastfeeding (Wright 1996). Furthermore, mothers who remain together with their infants reported more self-confidence and felt more competent in caring for their infants (O'Connor 1980) and likely to continue to breastfeed their infants longer than those mothers who had their infants separated. Apart from the positive effects on breastfeeding, rooming-in mothers may have a lower incidence of breast engorgement and milk stasis (Wilde 1999) due to frequent breast-suckling by the infant and better infant weight gain due to less energy consumption from crying during early infancy (Yamauchi 1990). Rooming-in may also be advantageous to infant's health as it is associated with lower incidence of neonatal diarrhoea (Mustajab 1986) and significant hyperbilirubinaemia (Suradi 1998) when compared to the infants in nursery care.

Why it is important to do this review

The benefits of breastfeeding especially exclusive breastfeeding for six months are well established (Kramer 2002; Victora 1987). However, the duration of exclusive breastfeeding globally remains low, with only an estimated 35% of infants being exclusively breastfed up to four months of age (WHO 2012). Among the factors in the early puerperium that contribute to failure to sustain lactation for a longer duration include the mother's condition after labour, psychological stress (Chen 1998), mode of delivery (Suradi 1998), individual cultural practice (Ingram 2003) and, most importantly, the maternal desire to breastfeed her infant. Mother-infant rooming-in is recommended by WHO/UNICEF Baby Friendly Hospital Initiative 1991 in the 10 steps to successful breastfeeding. It is believed to be the most favourable arrangement for optimal breast-milk production (WHO 1998). Although both separate care and rooming-in are traditional practices, the benefits and harms were not questioned. When hospitals became the primary place of birth separate care became the norm because of perceived benefits at that time. The benefits and harms have not been fully evaluated. Therefore, the aim of this review is to assess the effects of the practice of routine separation of mothers and babies, compared with the practice of routine rooming-in, on the duration of breastfeeding.

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Objectives

To assess the effect of mother-infant separation versus rooming-in on the duration of breastfeeding (exclusive and total duration of breastfeeding).

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Methods

Criteria for considering studies for this review

Types of studies

Randomised or quasi-randomised controlled trials including cluster-randomised trials.

Types of participants

All mothers who have given birth and are able to care for their normal newborn infants whether or not they have initiated breastfeeding. Trials recruiting populations with specific health problems such as AIDS were not be included in this review.

Types of interventions

Intervention

Mother and infant are placed separately. The primary site of care of the infant is in the hospital nursery throughout the hospital stay or, in the case of deliveries at home, the infant is cared for in a separate room by someone other than the mother.

Comparison

Mother and infant placed in the same room immediately after birth in the case of a home birth, immediately after leaving the labour or delivery room after a normal hospital birth or from the time when the mother is able to respond to her infant (in the case of caesarean section) where the infant is either bed-sharing by attached side-car crib or placed in a stand-alone cot by the bedside.

Types of outcome measures

Primary outcomes

Duration of breastfeeding as measured by one of the following.

  1. Mean duration of exclusive breastfeeding.
  2. Mean duration of any breastfeeding.
  3. Proportion of infants being exclusively breastfed at six months of age.
  • Exclusive breastfeeding is defined as an infant receiving only breast milk, without any additional food or supplement.
  • Any breastfeeding is defined as an infant receiving any amount of breast milk, regardless of supplements.
Secondary outcomes
  1. Mean frequency of breastfeeding per day.
  2. Rate of exclusive breastfeeding on discharge from the hospital.
  3. Maternal outcomes: rate of breast engorgement, maternal duration of sleep, maternal adverse events (wound breakdown, puerperal sepsis, fainting episode, postpartum haemorrhage), maternal satisfaction and level of mother's confidence in parenting.
  4. Neonatal outcomes: any neonatal infection, diarrhoea, hypoglycaemia, hypothermia, significant hyperbilirubinaemia needing therapy.

Search methods for identification of studies

Electronic searches

We contacted the Trials Search Co-ordinator to search the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2012).

The Cochrane Pregnancy and Childbirth Group’s Trials Register is maintained by the Trials Search Co-ordinator and contains trials identified from: 

  1. monthly searches of the Cochrane Central Register of Controlled Trials (CENTRAL);
  2. weekly searches of MEDLINE;
  3. weekly searches of EMBASE;
  4. handsearches of 30 journals and the proceedings of major conferences;
  5. weekly current awareness alerts for a further 44 journals plus monthly BioMed Central email alerts.

Details of the search strategies for CENTRAL, MEDLINE and EMBASE, the list of handsearched journals and conference proceedings, and the list of journals reviewed via the current awareness service can be found in the ‘Specialized Register’ section within the editorial information about the Cochrane Pregnancy and Childbirth Group External Web Site Policy

Trials identified through the searching activities described above are each assigned to a review topic (or topics). The Trials Search Co-ordinator searches the register for each review using the topic list rather than keywords.  

We did not apply any language restrictions. 

Data collection and analysis

Selection of studies

At least two review authors independently assessed for inclusion all the potential studies identified as a result of the search strategy. We resolved any disagreement through discussion.

Data extraction and management

We designed a form to extract data. For eligible studies, at least two review authors extracted the data using the agreed form. We resolved discrepancies through discussion. We entered data into Review Manager software (RevMan 2011) and checked it for accuracy.

When information regarding any of the above was unclear, we attempted to contact authors of the original reports to provide further details.

Assessment of risk of bias in included studies

At least two review authors independently assessed risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We resolved any disagreement by discussion.

(1) Random sequence generation (checking for possible selection bias)

We described for each included study the method used to generate the allocation sequence in sufficient detail to allow an assessment of whether it should produce comparable groups.

We assessed the method as:

  • low risk of bias (any truly random process, e.g. random number table; computer random number generator),
  • high risk of bias (any non-random process, e.g. odd or even date of birth; hospital or clinic record number) or,
  • unclear risk of bias.   
 (2) Allocation concealment (checking for possible selection bias)

We described for each included study the method used to conceal allocation to interventions prior to assignment and assess whether intervention allocation could have been foreseen in advance of, or during recruitment, or changed after assignment.

We assessed the methods as:

  • low risk of bias (e.g. telephone or central randomisation; consecutively numbered sealed opaque envelopes);
  • high risk of bias (open random allocation; unsealed or non-opaque envelopes, alternation; date of birth);
  • unclear risk of bias. 
(3.1) Blinding of participants, personnel and outcome assessment (checking for possible performance bias and detection bias)

We described for each included study the methods used, if any, to blind study participants and personnel from knowledge of which intervention a participant received. We consider studies to be at low risk of bias if they were blinded, or if we judge that the lack of blinding would be unlikely to affect results. We assessed blinding separately for different outcomes or classes of outcomes.

We assessed the methods as:

  • low, high or unclear risk of bias for participants;
  • low, high or unclear risk of bias for personnel;
  • low, high or unclear risk of bias.
(4) Incomplete outcome data (checking for possible attrition bias due to the amount, nature and handling of incomplete outcome data)

We described for each included study, and for each outcome or class of outcomes, the completeness of data including attrition and exclusions from the analysis. We state whether attrition and exclusions were reported and the numbers included in the analysis at each stage (compared with the total randomised participants), reasons for attrition or exclusion where reported, and whether missing data were balanced across groups or were related to outcomes.  Where sufficient information is reported, or was supplied by the trial authors, we re-include missing data in the analyses which we undertook.

We assessed methods as:

  • low risk of bias (e.g. less than 20% missing data; missing outcome data balanced across groups);
  • high risk of bias (e.g. numbers or reasons for missing data imbalanced across groups; ‘as treated’ analysis done with substantial departure of intervention received from that assigned at randomization);
  • unclear risk of bias.
(5) Selective reporting (checking for reporting bias)

We described for each included study how we investigated the possibility of selective outcome reporting bias and what we found.

We assessed the methods as:

  • low risk of bias (where it is clear that all of the study’s pre-specified outcomes and all expected outcomes of interest to the review have been reported);
  • high risk of bias (where not all the study’s pre-specified outcomes have been reported; one or more reported primary outcomes were not pre-specified; outcomes of interest are reported incompletely and so cannot be used; study fails to include results of a key outcome that would have been expected to have been reported);
  • unclear risk of bias.
(6) Other bias (checking for bias due to problems not covered by 1 to 5 above)

We described for each included study any important concerns we have about other possible sources of bias.

We assessed whether each study was free of other problems that could put it at risk of bias:

  • low risk of other bias;
  • high risk of other bias;
  • unclear whether there is risk of other bias.
(7) Overall risk of bias

We made explicit judgements about whether studies were at high risk of bias, according to the criteria given in the Handbook (Higgins 2011). With reference to (1) to (6) above, we assessed the likely magnitude and direction of the bias and whether we considered it is likely to impact on the findings.  If we had found sufficient studies, we planned to explore the impact of the level of bias through undertaking sensitivity analyses - see Sensitivity analysis

Measures of treatment effect

Dichotomous data

For dichotomous data, we presented results as a summary risk ratio with 95% confidence intervals. 

Continuous data

We had pre-specified that we would report continuous data as mean difference. However we did not find any continuous data that could be included.

Unit of analysis issues

Cluster-randomised trials

Due to global implementation of Baby-Friendly Hospital Initiatives, we expected some cluster-randomised trials where hospitals or postnatal wards were considered the natural unit of randomisation for logistic convenience in the implementation of the intervention. No cluster-randomised trials were identified for inclusion but if we identify trials of this design in future updates of this review we will include them in the analyses along with individually-randomised trials. We will adjust their sample sizes using the methods described in the Handbook using an estimate of the intracluster correlation co-efficient (ICC) derived from the trial (if possible), from a similar trial or from a study of a similar population. If we use ICCs from other sources, we will report this and conduct sensitivity analyses to investigate the effect of variation in the ICC. If we identify both cluster-randomised trials and individually-randomised trials, we plan to synthesise the relevant information. We will consider it reasonable to combine the results from both if there is little heterogeneity between the study designs and the interaction between the effect of intervention and the choice of randomisation unit is considered to be unlikely.

We will also acknowledge heterogeneity in the randomisation unit and perform a subgroup analysis to investigate the effects of the randomisation unit.

Dealing with missing data

For the one included study, we noted levels of attrition. If we had included sufficient studies, we would have explored the impact of including studies with high levels of missing data in the overall assessment of treatment effect by using sensitivity analysis.

For all outcomes, we carried out analyses, as far as possible, on an intention-to-treat basis, i.e. we attempted to include all participants randomised to each group in the analyses, and all participants were analysed in the group to which they were allocated, regardless of whether or not they received the allocated intervention. The denominator for each outcome in each trial was the number randomised minus any participants whose outcomes are known to be missing.

Assessment of heterogeneity

If we had found more than one study that could be combined in a meta-analysis, we would have assessed statistical heterogeneity in each meta-analysis using the T², I² and Chi² statistics. We would have regarded heterogeneity as substantial if the I² was greater than 30% and either the T² was greater than zero, or there was a low P value (less than 0.10) in the Chi² test for heterogeneity. 

Assessment of reporting biases

If we had included 10 or more studies in the meta-analysis, we would have investigated reporting biases (such as publication bias) using funnel plots. We would have assessed funnel plot asymmetry visually, and used formal tests for funnel plot asymmetry. For continuous outcomes, we would have used the test proposed by Egger 1997, and for dichotomous outcomes, we would have used the test proposed by Harbord 2006. If asymmetry was detected in any of these tests or was suggested by a visual assessment, we would have performed exploratory analyses to investigate it.

Data synthesis

We carried out statistical analysis using the Review Manager software (RevMan 2011). If we had found suitable studies, we would have used fixed-effect meta-analysis for combining data where it was reasonable to assume that studies were estimating the same underlying treatment effect: i.e. where trials were examining the same intervention, and the trials’ populations and methods were judged sufficiently similar. If there was clinical heterogeneity sufficient to expect that the underlying treatment effects differ between trials, or if substantial statistical heterogeneity was detected, we would have used random-effects meta-analysis to produce an overall summary, if an average treatment effect across trials was considered clinically meaningful. The random-effects summary would have been treated as the average range of possible treatment effects and we would have discussed the clinical implications of treatment effects differing between trials. If the average treatment effect was not clinically meaningful we would not have combined trials.

If we had used random-effects analyses, the results would have been presented as the average treatment effect with its 95% confidence interval, and the estimates of  T² and I².

Subgroup analysis and investigation of heterogeneity

In future updates of this review, if we identify substantial heterogeneity, we will investigate it using subgroup analyses and sensitivity analyses. We will consider whether an overall summary is meaningful, and if it is, use random-effects analysis to produce it.

In future updates of this review, as more data become available, we plan to carry out the following subgroup analyses to compare the differential effect of the intervention by mode of delivery (normal delivery versus caesarean section), by parity (primipara versus multipara) and by the infant sleeping allocation (bed-sharing versus bedside cot).

Subgroup analyses will be restricted to the primary outcomes:

  • mean duration of exclusive breastfeeding;
  • mean duration of any breastfeeding;
  • proportion of infants exclusively breastfed at six months of age.

For fixed-effect inverse variance meta-analyses, we will assess differences between subgroups by interaction tests. For random-effects and fixed-effect meta-analyses using methods other than inverse variance, we will assess differences between subgroups by inspection of the subgroups’ confidence intervals; non-overlapping confidence intervals indicate a statistically significant difference in treatment effect between the subgroups.

Sensitivity analysis

In future updates of this review, as more data become available, we will carry out sensitivity analysis to explore the effect of trial quality. This will involve analyses excluding studies at risk of selection bias or attrition bias. Studies of poor quality (rated as 'inadequate' or 'unclear' for allocation concealment; sequence generation; or incomplete outcome assessment), will in future updates be excluded from the analysis in order to assess for any substantive difference to the overall result.

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Main results

Description of studies

We found 23 reports from 19 available trials. Only one trial (Bystrova 2008) met our inclusion criteria. This is a thesis that was reported in four publications, two of which contributed data to our review. The study was a 4x2 factorial design involving a total of 176 mothers who were randomly assigned to the four main treatment groups. The four treatment groups were 1) skin-to-skin contact at birth with rooming-in 2) no skin-to-skin contact with rooming-in 3) no skin-to-skin contact with 24 hours nursery care and 4) no skin-to-skin contact with rooming-in delayed up to three hours after birth. The overall aim of the thesis was to explore the role of closeness versus separation on infant and maternal outcomes, including breastfeeding outcomes. Breastfeeding outcomes on day four postpartum were reported in one of the papers, The authors reported the overall duration of 'nearly exclusive' breastfeeding as a median. In this review, we included the reported 'nearly exclusive' breastfeeding outcome as our pre-specified outcome 'any breastfeeding'. For further details of the trial, see Characteristics of included studies.

One excluded study (Perez-Escamilla 1992) met our objective of comparing separate care with rooming and reported our pre-specified outcome rate of breastfeeding at discharge, eight, 70 and 135 days postpartum. However, this study was excluded because the participating mothers were not randomly assigned to separate care or rooming. There were four other non-randomised controlled trials and none of these met our inclusion criteria for the intervention. The other 14 trials were excluded because the intervention did not meet our inclusion criteria. For further details of these studies, see Characteristics of excluded studies.

Risk of bias in included studies

Bystrova 2008 used a table to generate a random sequence and sequentially numbered opaque sealed envelopes to achieve allocation concealment. It was reported that both 'the researchers and the recruited women were blinded to the task' but the blinding method was not stated. It is not clear whether there was blinding of the outcome assessors. From the total of 176 mother-infant pairs randomised, 23 (13%) participants were excluded pre-intervention, 141 were analysed at day four outcomes and 141 at one, three and six months (attrition rate 20%). There were no significant differences between the 23 mothers who were excluded and the 141 mothers who participated in the study with respect to education background or the other background variables and exclusions were balance between the two groups. The analysis was not by intention-to-treat because 12 mothers were excluded before the intervention as they would not comply with the assigned intervention. Data for these 12 women are not available. Further details can be found in the 'Risk of bias' table, see Characteristics of included studies.

Effects of interventions

Only one randomised trial (Bystrova 2008), involving 176 women, contributed data to the outcomes of interest, i.e. mean duration of any breastfeeding, mean frequency of breastfeeding per day and the rate of infants exclusively breastfed on discharge from the hospital. However, the trial did not report the mean duration of exclusive breastfeeding; the proportion of infants exclusively breastfed up to six months of age; or any of the maternal or neonatal outcomes pre-specified in our protocol.

Primary outcomes

Mean duration of any breastfeeding

The Brystrova trial reported the mean frequency of breastfeeds per day on day four postpartum for the rooming-in group as 8.3 (SD 2.2), slightly higher that the separate care group, i.e. seven times per day. However, analysis of this outcome was not done since every infant in the separate care group was breastfed at a fixed schedule of seven times per day (SD = 0) resulting in no estimable comparison.They reported the overall median duration of any breastfeeding was four months and stated that there was no significant difference between the groups. The authors stated that they reported these data as a median because the distribution was skewed.

Secondary outcomes

Rate of exclusive breastfeeding

The rate of infants exclusively breastfed on day four postpartum before discharge from hospital was significantly lower in the separate care group, 45% (17/38) compared with 86% (99/115) in the rooming-in group (risk ratio (RR) 0.58; 95% CI 0.42 to 0.81; one trial, 141 women; Analysis 1.1).

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Discussion

There is insufficient evidence from randomised controlled trials to assess the effect of mother-infant separation versus rooming-in for increasing duration of breastfeeding and other maternal and fetal outcomes.

The included randomised controlled trial (RCT) (Bystrova 2008) did not evaluate all the important pre-specified outcomes, in particular it did not evaluate the proportion of infants exclusively breastfed up to six months of age as recommended by World Health Organization. The trial examined only healthy mother-infant pairs after a normal vaginal delivery and did not include healthy mother-infant pairs after operative delivery as we had intended to study. In addition, they did not report any of our pre-specified potentially harmful maternal and fetal outcomes such as rate of breast engorgement, maternal adverse events, neonatal infection, diarrhoea, and hypoglycaemia. Furthermore, in this study, the intervention had two components, i.e. separate care and a fixed feeding schedule of seven feeds per day compared with rooming-in and demand feeding. To answer our research question the only difference between the two groups should be the place of care and both groups should have either demand feeding or fixed feeding schedule.

One of our excluded studies, Perez-Escamilla 1992, was a non-randomised trial comparing breastfeeding rates at discharge, eight, 70 and 135 days postpartum in 165 healthy mothers birthing in one hospital with separate care and one with rooming-in and breastfeeding guidance. The study reported a significantly higher rate of exclusive breastfeeding at four months among primiparous women at the rooming-in hospital but not among multiparae. Similarly in Sousa 1974. 200 mother-infant pairs received either, immediate separation and nursery care with seven scheduled visits per day, or immediate contact and rooming-in. This study reported ‘successful’ breastfeeding up to two months in 77% of the rooming-in group compared with 27.4% in the nursery group. This study was reported only as an abstract and there is no indication in the abstract or any subsequent correspondence that this was a randomised or quasi-randomised study.

Although we have not managed to show a difference between rooming-in and separate care, where rooming-in is practiced, the bed arrangement may be important. Ball 2006 compared rooming-in with the cot beside the mother, at the end of the mother's bed or a side crib attached to the bed and found that the frequency of breastfeeding was greater when the cot was attached to the bed. However, Ball 2011 has subsequently shown on a population of 170 mother-infant pairs that these bedding arrangements do not affect breastfeeding duration.

Three others excluded studies (Ali 1981; Greenberg 1973; Lind 1986) examined separate care versus rooming-in, however the form of separate care and rooming-in did not meet our pre-specified criteria. Ali 1981 randomised mother-infant pairs to either 45 minutes contact followed by nine hours of separation or no contact for the first nine hours. Subsequently the contact was re-established but it was not clear whether this contact was in the form of rooming-in or nursery care. The study reported a significantly higher incidence of exclusive and partial breastfeeding at six and 12 weeks in the contact group. Greenberg 1973 randomised 100 primiparous mothers to separate care with scheduled feeding at night and day time rooming-in. However, no breastfeeding outcomes were measured. Lind 1986 randomised 344 mother-infant pairs to either separate care or day time rooming-in. The study reported a significantly higher incidence of breastfeeding at one month in the rooming-in group.

There is a need for properly designed RCTs so that women and health professionals can be confidently advised about the effect of separate mother-infant care practice on the duration of breastfeeding. Such studies should use relevant clinical outcomes such as mean duration of exclusive or any breastfeeding, proportion of infants exclusively breastfed for the duration of six months and other maternal and neonatal outcomes listed in this review.

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Authors' conclusions

Implications for practice

We found little evidence to support or refute the practice of mother-infant separation post delivery and cannot make a recommendation based on these data.

Implications for research

There is a need for a properly designed randomised controlled trial in this field to support or refute the practice of mother-infant separation after delivery for increasing duration of breastfeeding. Proper randomisation including concealed allocation and blinding of outcome assessors, and complete or near complete follow-up. are crucial. The intervention should be rooming-in for the entire duration of hospital stay as defined by the World Health Organization and outcome measures should include duration of exclusive breastfeeding and proportion of infants with exclusive or any breastfeeding at six months as well as the other secondary outcomes in this review. Consideration should be given to standardising the placement of the cot for the rooming-in mother-infant pair. In addition to a randomised controlled trial, it would be important to explore the process of rooming-in, using qualitative methods. This would provide insight into social and environmental factors that may support or hinder this practice

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Acknowledgements

We would like to acknowledge the contributions of the SEA-ORCHID group and members of the Cochrane Australasian Centre. We would like to thank Ksenia Bystrova for providing additional data for the Bystrova 2008 trial.

As part of the pre-publication editorial process, this review has been commented on by three peers (an editor and two referees who are external to the editorial team), a member of the Pregnancy and Childbirth Group's international panel of consumers and the Group's Statistical Adviser.

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Contributions of authors

Sharifah Halimah is the main author and guarantor for the review. She wrote the first draft of the protocol; provided a clinical and policy perspective as well as providing general advice on the development of the protocol. For the review she assessed studies for inclusion, assessed trial quality and extracted and analysed the data and wrote the review.

Lee Kim Seng helped to draft the protocol and provided a clinical perspective during protocol development as well as the review. For the review he assessed studies for inclusion and assessed trial quality.

Jacqueline Ho provided general comments and advice from the protocol development to the completion of the review. She assessed trial quality where disagreement arose in the decision to include or exclude trials.

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Declarations of interest

None known.

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Differences between protocol and review

The methods have been updated in accordance with the latest guidelines (Higgins 2011).

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Published notes

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Characteristics of studies

Characteristics of included studies

Bystrova 2008

Methods

This is a randomised controlled trial with 4x2 factorial design. The factorial design takes into account 2 factors, i.e. infant location and apparel.

A table of allocation sequence was drawn up in advance of the trial. The randomisation, in blocks of 8 was stratified for time and parity. Sequentially numbered opaque envelopes containing information on group assignment were sealed and numbered in the order they should be used. The mother-infant pairs were assigned into 4 intervention groups. Both the researchers and the recruited women were blinded to the task.

Data were recorded in the delivery ward at 25-120 minutes postpartum and later in the maternity ward.

Participants

176 (separate care: 44, rooming-in:132) healthy mother-infant dyads after normal spontaneous vaginal delivery. 23 participants excluded (separate care: 6, rooming-in: 17) leaving total of 153 (separate care: 38, rooming-in: 115) mother-infant pairs for study all of whom were included in the short-term outcomes up to 6 months. Data for breast feeding outcomes were available for 141 mothers.

Interventions

Group 1 infants (n = 37) were placed skin-to-skin on their mother's chest 25-120 minutes after birth, while still in the labour ward and later were dressed in clothes and taken to the maternity ward for rooming-in with their mother.

Group 2 infants (n = 40) were dressed and placed in their mother's arm 25-120 minutes after birth and then taken to the maternity ward for rooming-in with their mothers.

Group 3 infants (n = 38) were dressed and kept in the cot at the labour ward nursery 25-120 minutes after birth and stay in the nursery while their mother was in the maternity ward until discharged from the hospital.

Group 4 infants (n = 38 ) were dressed and kept in the cot at labour ward nursery 25-120 minutes after birth and later were taken for rooming-in with their mothers.

We analysed group 3 as the experimental group (separate care) and group 1, 2 and 4 as the control group (rooming-in).

In the rooming-in group, the mothers were encouraged to breastfeed their infants on demand while in the separate care group, the infants were taken to their mothers' room in the maternity ward at a fixed schedule of 7 times a day for breastfeeding.

Outcomes

Primary breast feeding outcomes: breastfeeding parameters on day 4 postpartum, i.e. frequency of breastfeeding per day, duration of each feed (mins), volume of milk ingested (ml), infant weight changes (grams) and rate of exclusive breastfeeding at discharge.

Secondary outcomes: mean duration of 'nearly exclusive' breastfeeding, and mother-infant interaction 1 year later using The Parent-Child Early Relational Assessment (PCERA) Method.

'Nearly exclusive' breastfeeding is analysed as any breastfeeding in this review.

Notes

This thesis was reported in the total of 5 publications, 2 of which contributed data to this review. Due to skewing of the data the duration of breastfeeding was analysed as a median and interquartile range. The mean and SD was supplied by the author who warned a skewed distribution of data.

Risk of bias table
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk

A table of allocation sequence was drawn up in advance of the trial.

Allocation concealment (selection bias) Low risk

The mother-infant pairs were randomly assigned according to allocation sequence using sealed opaque sequentially numbered envelopes for primiparas and multiparas.

Blinding (performance bias and detection bias) Unclear risk

It was reported that both 'the researchers and the recruited women were blinded to the task'. The method of blinding used for women and researchers was not stated. The blinding of the outcome assessors is not clear.

Incomplete outcome data (attrition bias) Low risk

23/176 (13%) of the mother-infant pairs excluded from the trial post randomisation, (6/38 (15%) from the separate care group and 18/138 (13%) from the rooming-in group. At 1. 3, 4 and 6 months follow-up there were 32 and 109 in the 2 respective groups (19.9%).

Selective reporting (reporting bias) Unclear risk

The methods section of one paper stated that breast feeding duration was studied at intervals up to 12 months however results were not reported in any of the study publications.

Other bias High risk

Besides the intervention there was a difference in the way the 2 groups were treated. Infants in the separate care group were taken to the mother's room for breastfeeding at a fixed schedule of 7 times per day (instead of allowing the mother to freely visit their baby in the nursery for breastfeeding or bringing the baby to the mother when the baby is ready for feeding). On the other hand, infants in the rooming-in group were breastfed on demand.

Footnotes

SD: standard deviation

Characteristics of excluded studies

Greenberg 1973

Reason for exclusion

This is a randomised controlled trial of 100 primiparous mothers who had an uncomplicated vaginal delivery. 50 mothers were assigned to room-in and the infant was brought to the mother within 12-36 hours after birth and remained in a cot from 9 am to 6 pm and later returned to the nursery. The other group of the mothers were assigned to a nursery care unit where their infants were placed in the open nursery. The outcomes measured in this study were mother's level of confidence and level of competence prior to leaving the hospital. Rooming-in in this study did not meet our defined rooming-in criteria and the study did not report any outcome measures relevant to our review.

Sousa 1974

Reason for exclusion

This trial reported only in abstract form, comparing separate care and rooming-in, is not clear how the mother-infant pairs were assigned. Two hundred mother-infant pairs were recruited after a normal vaginal delivery. 'Successful lactation' up to 2 months was measured.

Sosa 1976

Reason for exclusion

This is a randomised controlled trial of 160 primiparous mothers to determine the physical benefits of early mother-infant skin-to-skin contact. The mothers in the experimental groups had skin-to-skin contact with their infants at birth followed by rooming-in for only 45 minutes before the infants were placed in the nursery for their remaining hospital stay. The outcomes measured in this study were mean duration of breastfeeding in the first year, the rate of breastfeeding up to 1 year postpartum, affectionate behaviour, rate of infection and infant growth. Rooming-in in this study did not meet our pre-defined rooming-in criteria.

Hales 1977

Reason for exclusion

This is a randomised trial of 60 healthy primiparous mothers to assess the effect of mother-infant skin-to-skin contact after birth on mothers' affectionate behaviour towards the infants. The study did not meet our inclusion criteria.

Kantos 1978

Reason for exclusion

This non-randomised trial examined the effect of extended contact in the early postpartum hours and days on maternal attachment behaviour at 1 and 3 months. The study comparison group did not meet our pre-specified criteria of rooming-in.

O'Connor 1979

Reason for exclusion

This randomised trial only available in abstract form, examined the effect of rooming-in on enhancing mother-infant attachment. Seventy healthy mother-infant pairs were randomly assigned to receive separate care while the other 50 were assigned to rooming-in for the first 48 hours postpartum. Maternal-infant behaviour was observed up to 1 year. This study did not report any breastfeeding outcome.

Ali 1981

Reason for exclusion

This randomised trial examined the effects on later behaviour of a 45-minute period of contact immediately after birth between a woman and her full-term healthy newborn. A total of 100 mothers from a low-income group were recruited after uncomplicated vaginal delivery. Half (50) of the mothers were randomly assigned to the study group where they were allowed contact with their infants for 45 minutes followed by separate care for 9 hours before re-establishing contact. Both the intervention and comparison did not meet our pre-specified inclusion criteria.

Grossmann 1981

Reason for exclusion

This randomised controlled trial examined the effect of early and/or extended mother-infant tactile contact. This study did not meet any of our pre-specified inclusion criteria.

Keefe 1986

Reason for exclusion

This randomised trial compared the state of behaviour of newborns who were rooming-in with their mothers at night with those who were cared for in the traditional nursery at night. During the day all the infants were cared for in the nursery. The study comparison group did not meet our pre-specified criteria for rooming-in.

Lind 1986

Reason for exclusion

In this study 344 primiparas after uncomplicated vaginal delivery of term infants with birthweights of 3000 to 4000 grams were recruited and randomly selected to a rooming-in group (n = 172) where the newborns stayed with the mothers during the day time and returned to nursery during the night. The comparison group (n = 175) had separate care in the nursery until discharge. At discharge mothers completed questionnaires on duration of exclusive and any breastfeeding during the hospital stay. The study did not meet our pre-specified inclusion criteria for rooming-in.

Elander 1986

Reason for exclusion

The design of this study is quasi-random. However, the authors did not fully comply with allocation in that some participants were allocated by convenience. A total of 29 infants undergoing phototherapy to treat jaundice were alternately selected into separated care and rooming-in. However, when there was no empty single room available for rooming-in the infant was assigned to the separate care group. The age of the infants at allocation and the type of care prior to allocation was not described. .

Lindenberg 1990

Reason for exclusion

The study was carried out over 2 time periods. Women were assigned to separate care during the first time period and to rooming-in for the second time period. Women during the first period were randomised to two different types of separate care. The outcome reported measured was incidence of breastfeeding at 1 week and 4 months.

Perez-Escamilla 1992

Reason for exclusion

This trial was a non-random controlled comparison of rooming-in versus nursery care. 58 eligible women who delivered in Hospital A were assigned to nursery care and compared with 107 women assigned to rooming-in in Hospital B. The women in Hospital B were randomised to rooming-in and rooming-in with breastfeeding guidance. The outcome measured was duration of full and any breastfeeding.This study reported a significantly higher breastfeeding rate at 4 months among primiparae who had a childbirth at the rooming-in hospital and received breastfeeding guidance.

Segura-Millan 1994

Reason for exclusion

This randomised trial aimed to evaluate a maternity ward breastfeeding promotion programme and to identify factors related to perceived insufficient milk. Women were interviewed in the hospital, at 1 week, 2 months and 4 months postpartum for factors associated with perceived insufficient milk. This study did not meet our inclusion criteria.

Kastner 2005

Reason for exclusion

This randomised trial aimed to evaluate the impact of a first hour postpartum mother-infant contact on the mother-child relationship during the puerperium period. Immediately after delivery the mother-infant pairs were assigned either to a group where mother and child spent the first hour alone and the control group which follow labour room routine practice. This trial did not study rooming-in versus separate care of mother-infant pairs.

Ball 2006

Reason for exclusion

This randomised trial examined the effect of 3 rooming-in practices on the initiation of breastfeeding and infant safety. There was no separate care group.

O'Connor 1980

Reason for exclusion

This randomised trial examined the effect of rooming-in on the incidence of measures of parenting inadequacy. A total of 301 mother-infant pairs were randomly assigned to rooming-in (n = 143) where the infants were roomed-in with their mothers 7 hours after birth up to 8 hours each day until discharge. The other 158 mother-infant pairs had separate care after a glimpse of their baby at birth. Parental inadequacy was measured after 17 months by the rate of infestations, rate of accident, exanthematous disease and hospitalisation. Rooming-in in this study did not meet our definition of rooming-in.

Ball 2011

Reason for exclusion

This study compared the effect on breastfeeding duration of side-car cribs with stand alone cots in rooming-in mother infant pairs. There was no separate care group.

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Additional tables

None noted.

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References to studies

Included studies

Bystrova 2008

Published and unpublished data

Brystrova K, Matthiesen AS, Widstrom AM, Ransjo-Arvidson A, Welles-Nystrom B, Vorontsov I, et al. The effect of Russian Maternity Home routines on breastfeeding and neonatal weight loss with special reference to swaddling. Early Human Development 2007;83:29-39.

Brystrova K, Widstrom AM, Matthiesen AS, Ransjo-Arvidson A, Welles-Nystrom B, Vorontsov T, et al. Early lactation performance in primiparous and multiparous women in relation to different maternity home practices. A randomised trial in St. Petersburg. International Breastfeeding Journal 2007;2:9. [DOI: 10.1186/1746-4358-2-9]

Bystrova K, Ivanova V, Matthiesen A, Mukhamedrakhimov R, Ransjo-Arvidson AB, Mukhamedrakhimov R, et al. Early contact versus separation: effect on mother-infant interaction one year later. Birth 2009;36(2):97-109.

* Bystrova K. Skin to skin contact and suckling in early postpartum: effects on temperature, breastfeeding and mother-Infant interaction. A study in St. Petersburg, Russia [thesis]. Karolinska Institute, 2008.

Excluded studies

Ali 1981

Ali Z, Lowry M. Early maternal-child contact: effects on later behaviour. Developmental Medicine and Child Neurology 1981;23:337-45.

Ball 2006

Ball H. Sleeping and feeding in the first 6 months: test of a large-scale data collection technique. Journal of Reproductive and Infant Psychology 2004;22(3):231.

* Ball HL, Ward-Platt MP, Heslop E, Leech SJ, Brown KA. Randomised trials of infant sleep location on the postnatal ward. Archives of Disease in Childhood 2006;91(12):1005-10.

Ball 2011

Ball HL, Ward-Platt MP, Howel D, Russell C. Randomised trial of sidecar crib use on breastfeeding duration (NECOT). Archives of Disease in Childhood 2011;96(7):630-4. [PubMed: 21474481]

Elander 1986

Elander G, Lindberg T. Hospital routines in infants with hyperbilirubinaemia influence the duration of breastfeeding. Acta Paediatrica Scandinavica 1986;75:708-8.

Greenberg 1973

Greenberg M, Rosenberg I, Lind J. First mothers rooming-in with their newborns: its impact upon mother. American Journal of Orthopsychiatry 1973;43:783-69.

Grossmann 1981

Grossmann K, Thane K, Grossmann KE. Maternal tactual contact of the newborn after various postpartum conditions of mother-infant contact. Developmental Psychobiology 1981;19:454-61.

Hales 1977

Hales DJ, Lozoff B, Sosa R, Kennell JH. Defining the limits of maternal sensitive period. Developmental Medicine and Child Neurology 1977;19:454-61.

Kantos 1978

Kantos D. A study of the effects of extended mother-infant contact on maternal behaviour at one and three months. Birth and the Family Journal 1978;5:133-40.

Kastner 2005

* Kastner R, Gingelmaier A, Langer B, Grubert T, Hartl K, Stauber M. Mother-child relationship before, during and after birth [Die Mutter-Kind-Beziehung pranatal, unter der Geburt und postnatal]. Gynakologische Praxis 2005;29(1):109-14.

Kastner R, Gingelmaier A, Langer B, Grubert TA, Hartl K, Stauber M. Mother-child relationship before, during and after birth [Die Mutter-Kind-Beziehung pranatal, unter der Geburt und postnatal]. Padiatrische Praxis 2005;67(1):13-8.

Keefe 1986

Keefe MR. Comparison of neonatal nighttime sleep-wake patterns in nursery versus rooming-in environments. Nursing Research 1987;36:140-4.

Lind 1986

LInd J, Jaderling J. The influence of "rooming-in" on breastfeeding. Acta Paediatrica Scandinavica 1986;159:167.

Lindenberg 1990

Lindenberg CS, Artola RC, Jimenez V. The effect of early post-partum mother-infant contact and breast-feeding promotion on the incidence and continuation of breast-feeding. International Journal of Nursing Studies 1990;27(3):179-86.

O'Connor 1979

O'Connor S, Vietze PM, Sherrod K, Sandler H, Altemeier W. How does rooming-in enhance the mother-infant bond? Pediatrics 1980;66:176-82.

O'Connor 1980

O'Connor S, Vietze PM, Sherrod KB, Sandler HM, Altemeier WA. Reduced incidence of parenting inadequacy following rooming-in. Pediatric Research 1980;66:176-82.

Perez-Escamilla 1992

Perez-Escamilla R, Segura-Millan S, Pollitt E, Dewey K. Effect of the maternity ward system on the lactation success of low-income urban Mexican women. Early Human Development 1992;31:25-40.

Segura-Millan 1994

Segua-Millan S, Dewey KG, Perez-Escamilla R. Factors associated with perceived insufficient milk in urban population in Mexico. Journal of Nutrition 1994;124(2):202-12.

Sosa 1976

Sosa R, Kennel JH, Klaus MH, Urrutia JJ. The effect of early mother-infant contact on breastfeeding, infection and growth. In: Breastfeeding and the mother. Ciba Foundation Symposium 4. 1976:179-87.

Sousa 1974

Sousa PLR, Barros FC, Gazale RV, Begeres RM, Pinheiro GN, Menezes ST, et al. Attachment and Lactation. In: Proceedings of 14th International Congress of Pediatricia Buenos Aires, South America. 1974:136-8.

Studies awaiting classification

None noted.

Ongoing studies

None noted.

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Other references

Additional references

Becker 2008

Becker GE, McCormick FM, Renfrew MJ. Methods of milk expression for lactating women. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD006170. DOI: 10.1002/14651858.CD006170.pub2.

Buranasin 1991

Buranasin B. The effects of rooming-in on the success of breastfeeding and the decline in abandonment of children. Asia-Pacific Journal of Public Health 1991;5(3):217-20.

Chen 1998

Chen DC, Nommsen-Rivers L, Dewey KG, Lonnerdal B. Stress during labour and delivery and early lactation performance. American Journal of Clinical Nutrition 1998;68(2):335-44.

Daly 1993

Daly SE, Owens RA Hartmann PE. The short-term synthesis and infant-regulated removal of milk in lactating women. Experimental Physiology 1993;78(2):209-20.

Egger 1997

Egger M, Smith GD, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997;315:629-34.

Elander 1984

Elander G, Lindberg T. Short mother-infant separation during first week of life influences the duration of breastfeeding. Acta Paediatrica Scandinavica 1984;73(2):237-40.

Forster 2006

Forster DA, McLachlan HL, Lumley J. Factors associated with breastfeeding at six months postpartum in a group of Australian women. International Breastfeeding Journal 2006;12(1):18.

Harbord 2006

Harbord RM, Egger M, Sterne JA. A modified test for small-study effects in meta-analyses of controlled trials with binary endpoints. Statistics in Medicine 2006;25:3443-57.

Higgins 2011

Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane-handbook.org.

Hill 1996

Hill PD, Aldag JC, Chatterton RT. The effect of sequential and simultaneous breast pumping on milk volume and prolactin levels: a pilot study. Journal of Human Lactation 1996;12(3):193-9.

Hill 2005

Hill PD, Aldag JC, Chatterton RT, Zinaman M. Comparison of milk output between mothers of preterm and term infants: the first 6 weeks after birth. Journal of Human Lactation 2005;21(1):22-30.

Hiller 2006

Hiller K. Babies and bacteria: phage typing, bacteriologists, and the birth of infection control. Bulletin of the History of Medicine 2006;80:733-61.

Ingram 2003

Ingram J, John D, Hamid N. South Asian grandmothers' influence on breastfeeding in Bristol. Midwifery 2003;19(4):318-27.

Knight 1998

Knight CH, Peaker M, Wilde CJ. Local control of mammary development and function. Reviews of Reproduction 1998;3(2):104-12.

Kramer 2002

Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD003517. DOI: 10.1002/14651858.CD003517.

Lee 2007

Lee WT, Wong E, Lui SS, Chan V, Lau J. Decision to breastfeeding and early cessation of breastfeeding in infants below 6 months old - a population-based study of 3,204 infants in Hong Kong. Asia-Pacific Journal of Clinical Nutrition 2007;16(1):163-71.

Mustajab 1986

Mustajab I, Munir M. A rooming-in program for mothers and newborns at Gunung Wenang General Hospital Manado. Paediatrica Indonesiana 1986;26(9-10):177-84.

Neville 1988

Neville MC, Keller R, Seacat J, Lutes V, Neifert M, Casey C, et al. Studies in human lactation: milk outputs in lactating women during the onset of lactation and full lactation. American Journal of Clinical Nutrition 1988;48(6):1375-86.

Neville 2001

Neville MC, Morton J. Physiology and endocrine changes underlying human lactogenesis II. American Society for Nutritional Sciences Journal of Nutrition 2001;131:3005S-3008S.

Potter 2005

Potter B. Women's experiences of managing mastitis. Community Practice 2005;78(6):209-12.

RevMan 2011

Review Manager (RevMan) [Computer program]. Version 5.1. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2011.

Suradi 1998

Suradi R. Rooming-in for babies born by cesarean section in Dr Cipto Mangunkusumo General Hospital Jakarta. Paediatrica Indonesiana 1988;28(5-6):124-32.

Victora 1987

Victora CG, Smith PG, Vaughan JP, Nobre LC, Lombardi C, Teixeira AM, et al. Evidence for protection by breast-feeding against infant deaths from infectious diseases in Brazil. Lancet 1987;2(8554):319-22.

WHO 1998

World Health Organization. Evidence for the ten steps to successful breastfeeding (WHO/CHD/98.6). Geneva: WHO, 1998.

WHO 2012

World Health Organization. Global Databank on Breastfeeding. https://apps.who.int/nut/db_bfd.htm (accessed 2012).

Wilde 1995

Wilde CJ, Prentice A, Peaker M. Breast-feeding: matching supply with demand in human lactation. Proceedings of the Nutrition Society 1995;54(2):401-6.

Wilde 1999

Wilde CJ, Knight CH, Flint DJ. Control of milk secretion and apoptosis during mammary involution. Journal of Mammary Gland Biology and Neoplasia 1999;4(2):129-36.

Wright 1996

Wright A, Rice S, Well, S. Changing hospital practices to increase the duration of breastfeeding. Pediatrics 1996;97(5):669-75.

Yamauchi 1990

Yamauchi Y, Yamanouchi I. Breastfeeding frequency during the first 24 hours after birth in full-term neonates. Pediatrics 1990;86(2):171-5.

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Data and analyses

1 Comparison between separate care versus rooming-in

Outcome or Subgroup Studies Participants Statistical Method Effect Estimate
1.1 Proportion of infants exclusively breastfed at day 4 postpartum 1 141 Risk Ratio (M-H, Fixed, 95% CI) 0.58 [0.42, 0.81]

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Sources of support

Internal sources

  • KPJ Ipoh Specialist Hospital, Malaysia
  • Penang Medical College, Malaysia

External sources

  • SEA ORCHID Project, Malaysia

This review is published as a Cochrane review in The Cochrane Library, Issue 9, 2012 (see http://www.thecochranelibrary.com External Web Site Policy for information). Cochrane reviews are regularly updated as new evidence emerges and in response to feedback. The Cochrane Library should be consulted for the most recent recent version of the review.