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Design, Implementation, and Early Outcome Indicators of a New Family-Integrated Neonatal Unit
DESIGN, IMPLEMENTATION, AND EARLY OUTCOME INDICATORS
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NEONATAL UNIT DONNA MANN Nursing care models for neonates needing special care usually result in the separation of women from their newborns. Most special care nurseries (Level II) or NICUs (Level III) care for only neonates and not their mothers. Authors of review articles, including Cochrane systematic reviews, have reported that skinto-skin care (SSC) or kangaroo mother care (KMC), in which neonates are held skin to skin by a parent, reduces mortality, infection rates, and NICU length of stay (LOS) and improves growth parameters and breastfeeding rates at discharge (Conde-Agudelo, Belizán, & Díaz-Rossello, 2011; Conde-Agudelo & DíazRossello, 2014; Lawn, Mwansa-Kambafwile, Horta, Barros, & Cousens, 2010). Skin-to-skin care without separation of the newborn and woman after birth increases exclusive breastfeeding rates (Bramson et al., 2010; Crenshaw, 2014). In response to evidence that neonatal health outcomes are improved when newborns and their mothers stay together (Bhutta, Khan, Salat, Raza, & Ara, 2004; Erdeve et al., 2008; Levin, 1994), a new model of care, known as family care, has been developed (Örtenstrand et al., 2010). In the family care model, nurses and other clinicians care for neonates and their mothers together in a family care suite. The family is encouraged to stay and be coached to be the newborn’s primary caregivers. This care model provides for SSC and nonseparation of the family unit, especially just after birth; care by parents early in the hospital stay; and coaching for parents to be the primary caregivers of their newborns. This model has been shown to decrease LOS and lower risk for morbidities for newborns at greater risk (Örtenstrand et al., 2010). The compelling benefits associated with this model of care motivated clinicians at our hospital to build our new Special Care Nursery (SCN) with a design that would specifically facilitate this family care model. In this article we review the evidence for family care and describe how this model of care was planned and implemented at our institution. We also discuss the experience, lessons learned, and suggestions for future research. Abstract: Neonatal units are becoming more family-centered based on evidence of improved health outcomes when parents provide care to newborns. Physical environment constraints, as well as nursing care traditions and practices, have been barriers to providing care that includes close parental involvement. Our hospital’s experience in implementing a unique model of family-centered care in a Level II nursery suggests that this model of care is beneficial to families, satisfying to health care providers, and a viable model for practice. Some basic outcome data are discussed along with suggestions for future research. http://dx.doi.org/10.1016/j.nwh.2016.01.007 Keywords: family-integrated care | models of care | neonatal | NICU | skin-to-skin
Historical Perspectives on Neonatal Care Neonatal nursing units in the United States, designed to care for newborns requiring specialized care, have evolved over time. In the early 1900s, physicians believed that the best way of providing care entailed keeping parents out because of concern that these fragile newborns were vulnerable to infection and stress (Thomas, 2008). Parents were not allowed to touch their newborns, and families could view them only through a glass window (Thomas, 2008). By the 1960s, 80% of births were occurring in the hospital as opposed to in the family home, obstetrics had become a prominent specialty, and many newborn nurseries in hospitals were established (Thomas, 2008). Small “premie” nurseries from the 1960s grew during the 1970s and 1980s into
for healthy, full-term newborns throughout the United States. The couplet care model is supported by studies in which researchers show that early SSC, initiated ideally at birth, is associated with greater rates of breastfeeding and exclusive breastfeeding, increased breastfeeding duration, increased glucose levels within the first few hours after birth for full-term infants, and improved cardiovascular stability for late preterm infants (Bramson et al., 2010; Moore, Anderson, Bergman, & Dowswell, 2012). However, it is not only full-term and late preterm infants who benefit from close proximity to their parents. Authors of studies on KMC for preterm infants show that KMC is associated with a reduction in mortality at discharge or at 40 to 41 weeks postconceptual age, infection, hypothermia, and
large open units filled with incubators, bright lights, and noise from the addition of new medical equipment for monitoring, ventilating, and warming newborns (White & Newbold, 1995). By the 1990s, clinicians began to recognize the need for a less toxic environment that would foster development and healing by diminishing stimulation (White & Newbold, 1995). In addition, advances in developmental care of hospitalized preterm infants during the 1980s and 1990s began to emphasize the importance of parents’ participation in care (Thomas, 2008). Some NICUs began to offer space for parents to roomin, which was already the norm for well-newborn and pediatric wards (White & Newbold, 1995). With continually emerging data on KMC, SSC, and care by parent, neonatal caregivers are realizing that the optimal environment for premature infants is in close physical contact with parents (Bhutta et al., 2004; Conde-Agudelo et al., 2011; CondeAgudelo & Díaz-Rossello, 2014; Erdeve et al., 2008; Lawn et al., 2010; Levin, 1994). This paradigm shift necessitates a change in both the physical environment and the model of care provided to newborns requiring specialized care early in life.
Evidence for the Family Care Model Labor, delivery, recovery, and postpartum (LDRP) units have also evolved over the years. Couplet care, when women and newborns are cared for together, is now the standard of care Donna Mann, MSN, is a neonatal nurse practitioner at Catholic Medical Center in Manchester, NH. The author reports no conflicts of interest or relevant financial relationships. Address correspondence to: donna@ mannclan.us.
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length of hospital stay (Conde-Agudelo et al., 2011). KMC is also associated with increased weight gain, exclusive breastfeeding, or any breastfeeding at discharge and at further followup (Conde-Agudelo et al., 2011). Researchers in the field of epigenetics have provided evidence in rodent models that care by parent, especially within the first week of life, is actually associated with changes in DNA methylation, leading to expression of different genes and behaviors (Kaffman & Meaney, 2007; Szyf, Weaver, & Meaney, 2007). Perhaps these results may be found for human newborns as well, suggesting that the early environment for human infants may also influence DNA and gene expression. This would further strengthen the evidence for keeping parents and newborns together. Authors of an article reviewing research related to epigenetics and family-centered care report that although there are limited epigenetic studies on human newborns, inferences can be made that long-term epigenetic adaptations related to environment occur in preterm infants similar to those observed in animals (Samra, McGrath, Wehbe, & Clapper, 2012). Authors of a study of preterm infants born before 28 weeks gestation who were given a newborn individualized developmental care and assessment program, initiated by 72 hours of life and continued for 2 weeks, found that the infants had significantly improved neurobehavioral function at 2 weeks that continued to 9 months. The infants who received developmental care provided by both nurses and parents were better able to self-regulate and had improved state stability and threshold of responsiveness. They also had changes in electroencephalogram results consistent with improved motor organization, symmetry, and expression of attention (Als et al., 2004).
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Opening photo © Colleen Ellse, Background photo © Banana Stock / thinkstockphotos.com
THE COMPELLING BENEFITS ASSOCIATED WITH THIS MODEL OF CARE MOTIVATED CLINICIANS AT OUR HOSPITAL TO BUILD OUR NEW SPECIAL CARE NURSERY (SCN) WITH A DESIGN THAT WOULD SPECIFICALLY FACILITATE THIS FAMILY CARE MODEL
Photo © Colleen Ellse
Another population of infants at risk for complications is late preterm infants (34–36 weeks gestation). Late preterm births account for 75% of all preterm births. Compared with full-term infants, these infants are more susceptible to early morbidities and long-term developmental problems, including greater rates of respiratory distress, apnea, transient tachypnea, hypoglycemia, hypothermia, hyperbilirubinemia, seizures, and feeding problems. In addition, late preterm infants are 3 times more likely to develop cerebral palsy, have a 24% increased chance of reading scores below average in first grade, and are at increased risk for other developmental delays and the need for special education than children born at term gestation (Arpino et al., 2010). Authors of recent studies on infants born at 37 to 38 weeks gestation have shown that these newborns have greater incidences of hypoglycemia, need for respiratory support, need for intravenous fluids, and need for intravenous antibiotics, leading to increased admissions to special care units, than their full-term counterparts (Ghartey et al., 2012; Mally, Agathis, & Bailey, 2015; Parikh et al., 2014; Sengupta et al., 2013). Infants born late preterm and early term are also at increased risk for asthma and bronchitis during early childhood up to age 5 years compared with full-term infants (Odibo et al., 2016). The benefits of family-centered care and family-integrated care models for both full-term and late preterm infants are compelling. The evidence supports incorporating the family
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into the everyday care of the newborn. Many neonatal units now have single rooms, and parents are encouraged to stay to be their infant’s primary caregiver, with the support of the nursery staff. Evidence of benefits have been seen in Pakistan, where Bhutta et al. (2004) showed that recovering preterm infants whose mothers provided care in the hospital had decreased LOS and no increase in mortality or readmission. Wataker, Meberg, and Nestaas (2012) reported that in Norway, mothers residing with and providing care for their preterm infants 24 hours per day had higher confidence levels in caring for their infants and improved maintenance of breastfeeding after discharge. In Sweden, the family care model, with at least one parent caring for an infant born between 27 and 37 weeks gestation, led to decreased LOS and reduced risk of bronchopulmonary dysplasia (Örtenstrand et al., 2010).
Planning and Implementing the Family Care Model Family-centered care, care by parent, and parents rooming-in 24 hours per day with their infants have been shown to provide developmentally nurturing care and were the inspiration for the design of a new SCN at Catholic Medical Center in Manchester, NH. Modeled after the successful Karolinska units in Sweden (Örtenstrand et al., 2010), the goal for the SCN was to take the family-centered care model to a new level and to
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the design could be incorporated into our new unit. In addition, she reached out to a group of parents who had previously given birth to infants needing some extra care at Catholic Medical Center. These parents participated in a dinner and focus group and shared which practices and experiences were barriers to family-centered care and rooming-in with their newborns, as well as which supported and promoted family care. Using information from the Swedish model and the feedback from our own families, our director began working with architects to design a unit to fit in the space allocated by the hospital. Our planners were excited and eager to inaugurate this model of care in a new Level II nursery. With the goal to minimize separation of the family as much as possible, the new unit was designed to have space for parents to stay and also for staff to be able to care for women during their first few postpartum days. The unit was designed to have four family care suites, where the family would go for special care of the infant and care of the woman together. These rooms have space and appropriate equipment to care for women and newborns, as well as a sleeper sofa for a second parent or support person to room-in with them. In addition, to meet the needs of families once a woman is discharged, the unit was also designed with four special care rooms that can house four families. These special care rooms are equipped to provide medical and nursing care for infants, with accommodations for families to stay 24 hours a day, 7 days a week. They include room for two
Photo © Government of Alberta / flickr.com
provide care for all newborns that minimizes, if not eliminates, separation of the family unit. The need for a Level II unit at Catholic Medical Center arose in conjunction with a new group of obstetricians and midwives wanting to move their birth service to our hospital and have higher level neonatal care available. This provided the essential impetus needed for building a new neonatal care unit. Initially, design ideas began with a very traditional model of care in mind. However, the soon-to-be medical director had recently visited the Karolinska units in Sweden where the family care model was being practiced, and he proposed this model of care for our new unit. At Karolinska, premature infants, with the exception of extremely-low-birth-weight infants, were being cared for in this family care model. The thing that most impressed him was how natural it was for these families to be there caring for their newborns. He experienced the care as feeling comfortable and noted that the unit was truly designed to welcome and support the families who were staying for long periods of time. A nearby hotel provided food service for the parents. Prepared meals were left in the refrigerator, and parents could heat them up when needed. There were very nice communal spaces for families to use as well, including a kitchen and dining area. The director of maternal–child services at Catholic Medical Center attended a developmental care conference describing the Swedish model (Örtenstrand et al., 2010) to explore how
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parents to sleep, a refrigerator for breast milk, and a TV. The unit is also equipped with a common area that includes kitchen amenities, a washer and dryer, and a playroom for siblings or space for additional family members to gather. Nursing and medical staff for the new family-integrated unit were recruited through advertising, open houses, and direct connections. Several of the special care nurses came from the already existing LDRP unit, and others came from a wide variety of Level II and Level III units, mostly in the New England area. Because this model of care was totally new to the United States and staff came from varied backgrounds, it was important to put together a comprehensive orientation program. A key part of the orientation included a focus on the benefits of family care and the science behind this new model. Orientation also included information on how to operationalize this unique model on a day-to-day basis. In addition, nurses coming from the LDRP unit needed training in more advanced neonatal skills. Because the unit was not yet open, this training included didactic classes and observation time at a Level III unit associated with the hospital. Didactic classes on higher-level care of newborns included respiratory support, fluid management, and many other issues related to prematurity. Originally, the LDRP nurses were going to come to the family care suites to provide care for women, and the SCN nurses would care for high-risk newborns only. Over time, it became apparent that having the same nurse for the whole family would better support the family care model and allow for smoother workflow. The SCN nurses were then provided with education in the care of postpartum women, and they received clinical orientation on the LDRP unit.
Minimizing Separation of Women, Newborns, and Families Not only was the physical environment designed to minimize separation, but other aspects of care were considered as well. A respiratory device we named the “bridge” was created to allow a newborn with mild respiratory distress to stay in the labor room during the initial postpartum recovery period. Our “bridge” consists of a continuous positive airway pressure (CPAP) machine set up on a portable pole with oxygen and air tanks. This allows a newborn having respiratory distress to be started on CPAP in the birthing room, to be cared for by an SCN nurse, and to remain with the parents until the woman has recovered enough to be moved to the family care suite. Of course, safety is never compromised to keep everyone together. If a newborn is no longer stable, other interventions are provided as needed. These may include intubation, mechanical ventilation, placement of umbilical lines, and other necessary procedures. As much as possible, procedures are performed in the family’s room to minimize separation. Intravenous line placement and laboratory work are generally done
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OVER TIME, IT BECAME APPARENT THAT HAVING THE SAME NURSE FOR THE WHOLE FAMILY WOULD BETTER SUPPORT THE FAMILY CARE MODEL AND ALLOW FOR SMOOTHER WORKFLOW while the newborn is skin to skin to minimize separation and pain for the newborn. Minimizing separation of women and newborns requires nurses from both units to be flexible and help with assignments so that the new family can be cared for without separation whenever possible. The SCN nursery staffing is adjusted to allow the SCN nurse to stay in the birthing room until the mother has recovered from birth and the family is able to go to the family care suites together. The LDRP unit staffing is also sometimes adjusted to have labor and delivery nurses care for a woman in the family care suite if she requires more specialized maternity care than is feasible for SCN staff. Nursing staff are trained to be able to float between units as necessary as well.
Challenges and Lessons Learned With any change, once the new idea has been set in motion, it is necessary for staff to transition to a new way of thinking (Shirey, 2013). Couplet care is new for nurses experienced in caring only for newborns and not their mothers. In addition, family care requires SCN staff to give up control of many things they are accustomed to managing themselves. With a move toward empowering the family to have control and be the main caregivers, nurses perform more of a coaching role than their more traditional “doing” role. Traditions such as taking the newborn out of the room for different procedures or to give the family a break are replaced by all care being provided in the room with parents present. These changes have sometimes required staff to remind and encourage each other to continue to provide care with minimal separation, review progress at team meetings, and strategize together to meet the needs of both nurses and families. One challenge we have encountered is caring for women too ill to be adequately cared for in the family care suites. For example, if a woman is still requiring magnesium sulfate for very high blood pressure, she remains on the LDRP unit with nurses skilled at high-risk maternity care. One solution to this challenge has been to have the newborn stay on the LDRP unit and use telemetry to monitor the newborn from the Level II
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BASED ON PATIENT SATISFACTION SURVEYS, THIS MODEL OF CARE IS VALUED BY PARENTS AND ENHANCES THEIR CONFIDENCE TO CARE FOR THEIR NEWBORNS AT DISCHARGE nursery until the mother is well enough to move to the family care suites. This is successful if the newborn is stable enough to be cared for on the LDRP unit and staffing of both units supports this care. In other situations, staffing or patient acuity does not allow for keeping the family together when a woman is acutely ill, and the newborn is cared for separately in the SCN. Fathers and other family members designated by the woman may care for the newborn until the woman is stable enough to be transferred to the family care suites. Other solutions are still being explored. Nurse staffing is another challenge we have encountered. If there are too few SCN nurses to have one remain in the LDRP room for 1 to 2 hours of postpartum recovery before the woman and high-risk newborn can be transferred to the family care suite together, the family may need to be separated briefly. Most of the time our goal of nonseparation can be achieved, but staffing can be a barrier to fully providing our model of care at times. Factors related to the families also play a role in successful implementation of this model of care. Social and economic factors for parents, such as work obligations, may not allow them time to room-in with their newborns. Unlike in Sweden, where the family care model was initiated, parents in the United States are not guaranteed paid maternity or paternity leave from their jobs. In addition, the responsibility to care for other children at home can also be a barrier to having parents stay and spend significant time with their newborn in the family care suites. Some parents are reluctant to stay with their newborns. This may be attributable to a lack of understanding of the benefits of their presence or because they do not support the family care concept. In our experience, some families merely need to be informed of the benefits. Others decline to room-in with their newborns even after education and encouragement. In this case, the care of the high-risk newborn becomes more similar to traditional SCN models, with nurses providing the majority of care. Our experience with families rooming-in 24/7 has also led us to create a good citizens contract that families are given and sign on admission. It spells out expectations very clearly so that both nursing staff and families have an agreement about behavior and rules at the time of admission. It is not meant to set a rigid tone, but we found it helpful for families to know expectations up front, including everything from visiting guidelines to acceptable clothing.
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Other challenges in the operation of this type of unit include trying to account for costs across separate nursing units. The nursing care of mothers now moved to the SCN unit needed to be accounted for and billed to payers using a separate cost center. Currently, all revenue for the woman’s care is credited to the LDRP unit. Lessons were learned with regard to planning and evaluating outcomes. As we discuss in the next section, we do not have many outcome data, and those that we have may not be all that helpful. It is always prudent to begin with the end in mind, but because of an expedited deadline for opening the unit, plans were not put in place to identify, track, or measure different indicators of success. We can now see that the percentage of newborns placed skin to skin at birth, amount of time spent skin to skin at birth and daily throughout their hospitalization, percentage of families who were eligible for nonseparated care at birth who actually received it, amount of time parents spend rooming-in, and amount of time parents are actively caring for their newborns would be important things to have recorded and followed. Breastfeeding outcomes were followed, but more detailed information on women’s intent related to each newborn, not just overall percentages, would also be helpful. Long-term data on breastfeeding, meeting of developmental milestones, and parent confidence levels after discharge would also be useful items to measure. Identifying a comparison group of similar newborns with similar diagnoses and gestational ages receiving standard care might also be helpful in measuring success.
Outcomes With four family care suites, four special care rooms that can be doubled up if needed, and room in an observation area, the unit has 13 beds available and has had an average daily census of 7 to 8 over the past several years. The primary diagnosis from 2010 through 2014 was prematurity, accounting for 57% of admissions. Based on patient satisfaction surveys, this model of care is valued by parents and enhances their confidence to care for their newborns at discharge. Although the average LOS for high-risk newborns varies based on many factors, we suspect that this model of care has shortened the LOS or at least allowed for discharge at earlier adjusted postconceptual ages. We know that LOS is valuable in terms of cost savings, but we do not know if LOS is really a measure of success for our new model of care. Perhaps long-term follow-up data
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With regard to effects on breastfeeding, our data from 2014 show that 24.5% of our special care newborns were exclusively breastfeeding at discharge; 83% went home receiving a combination of breast milk and formula feedings. Only 17% were discharged with full formula-feeding. Staff response to this model has been overwhelmingly positive. As a health care provider, I find it rewarding to see families together from birth to discharge. Nurses and other members of the health care team have expressed that it is satisfying to send premature newborns home exclusively breastfeeding.
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Implications for Future Research
would be a better measure. We do not have the ability to compare data because there was only a Level I nursery at Catholic Medical Center before the opening of the SCN. Data on LOS specific to late preterm infants are minimal. We found one report by the March of Dimes (2011) reviewing data from 2009 and 2010 in which authors reported an overall LOS of 13.2 days. This is difficult to interpret because of the inability to compare populations. Interestingly, though, our data from 2010 show an overall average LOS of 13.2 days as well. In later years our overall LOS has increased, but our number of admissions from tertiary care centers has also increased, with extremely preterm infants coming to our unit to convalesce. Our data from 2014 show that for neonates born between 32 and 35 weeks (n = 27), the average postconceptual age at discharge from our SCN was 36 3/7 weeks. For newborns born between 26 3/7 and 35 weeks gestation that were transferred to us for continuing care from a Level III unit (n = 30), the average age at discharge was 37 weeks postconceptual age.
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Based on the past 5 years of experience since the unit was opened, both patients and staff consider this model to be beneficial to the family unit and one that should be continued. Outcomes for our infants with regard to breastfeeding, bonding, and age at discharge appear to be positive. Other research questions have emerged that will form the basis for ongoing and future data collection and help confirm the benefits of this model of care. Going forward we would like to determine if there is a correlation between breastfeeding and the following factors: amount of time spent skin to skin at birth, amount of time spent skin to skin throughout the hospital stay, and amount of time parents are rooming-in. We would particularly like to measure exclusive breastfeeding at discharge and longer-term breastfeeding data. In addition, it may be important to determine if parents’ time spent not simply in the room but actively providing care and/or being skin to skin with newborns is significant to these outcomes. Developmental outcomes should also be considered; infants will need to be followed up as outpatients to look at timing of developmental milestones or delays. The development of this unit has been challenging and rewarding for our hospital, and it appears to be of benefit to highrisk newborns and their families. Further research on LOS, feeding and developmental outcomes, cost, and staff satisfaction is warranted for our unit and for other units that are initiating this family-integrated model. Multisite studies and those with diverse populations of high-risk newborns could provide evidence that is needed to support development of units that a have family-integrated care model. We anticipate and encourage the development of similar units in other locations. NWH
Acknowledgment Thanks to all the nursing staff and health care providers of the Mom’s Place and Special Care Nursery, whose leadership, work,
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and collaboration help keep mothers and babies together, with special thanks to William Edwards, MD; Brenda Neff, RN, MSN, NE-BC; and Nicole Perdue-Pendenza, RN, BSN, RNCNIC. Thanks also to Deborah McCarter-Spaulding, PhD, RNC, for her encouragement and editorial guidance on this manuscript before its submission for publication.
implications of molecular insights. Journal of Child Psychology and Psychiatry, 48(3-4), 224–244. Lawn, J. E., Mwansa-Kambafwile, J., Horta, B. L., Barros, F. C., & Cousens, S. (2010). “Kangaroo mother care” to prevent neonatal deaths due to preterm birth complications. International Journal of Epidemiology, 39(suppl. 1), il44–il54. doi:10.1093/ije/dyq031 Levin, A. (1994). The Mother-Infant unit at Tallinn Children’s Hospital, Estonia: A truly baby-friendly unit. Birth, 21(1), 39–44. doi:10.1111/j.1523-536X.1994.tb00914.x
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Arpino, C., Compagnone, E., Montanaro, M. L., Cacciatore, D., De Luca, A., Cerulli, A., . . . Curatolo, P. (2010). Preterm birth and neurodevelopmental outcome: A review. Child’s Nervous System, 26(9), 1139–1149. doi:10.1007/s00381-010-1125-y
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Odibo, I. N., Bird, T. M., McKelvey, S. S., Sandlin, A., Lowery, C., & Magann, E. F. (2016). Childhood respiratory morbidity after late preterm and early term delivery: A study of Medicaid patients in South Carolina. Paediatric and Perinatal Epidemiology, 30(1), 67–75. doi:10.1111/ppe.12250
Bramson, L., Lee, J. W., Moore, E., Montgomery, S., Neish, C., Bahjri, K., & Melcher, C. L. (2010). Effect of early skin-to-skin motherinfant contact during the first 3 hours following birth on exclusive breastfeeding during the maternity hospital stay. Journal of Human Lactation, 26(2), 130–137. doi:10.1177/0890334409355779
Örtenstrand, A., Westrup, B., Broström, E. B., Sarman, I., Åkerström, S., Brune, T., . . . Waldenstrom, U. (2010). The Stockholm Neonatal Family Centered Care Study: Effects on length of stay and infant morbidity. Pediatrics, 125(2), e278–e285. doi:10.1542/ peds.2009-1511
Conde-Agudelo, A., Belizán, J. M., & Díaz-Rossello, J. (2011). Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. The Cochrane Database of Systematic Reviews, 2011(3), 1–56. doi:10.1002/14651858.CD002771.pub2
Parikh, L. I., Reddy, U. M., Männistö, T., Mendola, P., Sjaarda, L., Hinkle, S., . . . Laughon, S. K. (2014). Neonatal outcomes in early term birth. American Journal of Obstetrics and Gynecology, 211(3), 265.e1–265.e11. doi:10.1016/j.ajog.2014.03.021
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Samra, H. A., McGrath, J. M., Wehbe, M., & Clapper, J. (2012). Epigenetics and family-centered developmental care for the preterm infant. Advances in Neonatal Care, 12(suppl. 5), S2–S9.
Crenshaw, J. T. (2014). Healthy birth practice #6: Keep mother and baby together—It’s best for mother, baby, and breastfeeding. The Journal of Perinatal Education, 23(4), 211–217. doi:10.1891/1058-1243.23.4.211 Erdeve, O., Arsan, S., Yigit, S., Armangil, D., Atasay, B., & Korkmaz, A. (2008). The impact of individual room on rehospitalization and health service utilization in preterms after discharge. Acta Paediatrica, 97(10), 1351–1357. doi:10.1111/j.1651-2227.2008.00889.x Ghartey, K., Coletta, J., Lizarraga, L., Murphy, E., Ananth, C. V., & Gyamfi-Bannerman, C. (2012). Neonatal respiratory morbidity in the early term delivery. American Journal of Obstetrics and Gynecology, 207(4), 292.e1–292.e4. doi:10.1016/j.ajog.2012.07.022 Hung, K., & Berg, O. (2011). Early skin-to-skin after cesarean to improve breastfeeding. MCN: The American Journal of Maternal/Child Nursing, 36(5), 318–324. doi:10.1097/ NMC.0b013e3182266314 Kaffman, A., & Meaney, M. J. (2007). Neurodevelopmental sequelae of postnatal maternal care in rodents: Clinical and research
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Sengupta, S., Carrion, V., Shelton, J., Wynn, R. J., Ryan, R. M., Singhal, K., & Lakshminrusimha, S. (2013). Adverse neonatal outcomes associated with early-term birth. JAMA Pediatrics, 167(11), 1053–1059. doi:10.1001/jamapediatrics.2013.2581 Shirey, M. R. (2013). Lewin’s Theory of Planned Change as a strategic resource. Journal of Nursing Administration, 43(2), 69–72. doi:10.1097/NNA.0b013e31827f20a Szyf, M., Weaver, I., & Meaney, M. (2007). Maternal care, the epigenome and phenotypic differences in behavior. Reproductive Toxicology, 24(1), 9–19. Thomas, L. M. (2008). The changing role of parents in neonatal care: A historical review. Neonatal Network, 27(2), 91–100. Wataker, H., Meberg, A., & Nestaas, E. (2012). Neonatal family care for 24 hours per day: Effects on maternal confidence and breast-feeding. The Journal of Perinatal and Neonatal Nursing, 26(4), 336–342. doi:10.1097/JPN.0b013e31826d928b White, R., & Newbold, P. A. (1995). Reinventing the newborn ICU. The Healthcare Forum Journal, 38(2), 30–33.
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NEONATAL UNIT DONNA MANN Nursing care models for neonates needing special care usually result in the separation of women from their newborns. Most special care nurseries (Level II) or NICUs (Level III) care for only neonates and not their mothers. Authors of review articles, including Cochrane systematic reviews, have reported that skinto-skin care (SSC) or kangaroo mother care (KMC), in which neonates are held skin to skin by a parent, reduces mortality, infection rates, and NICU length of stay (LOS) and improves growth parameters and breastfeeding rates at discharge (Conde-Agudelo, Belizán, & Díaz-Rossello, 2011; Conde-Agudelo & DíazRossello, 2014; Lawn, Mwansa-Kambafwile, Horta, Barros, & Cousens, 2010). Skin-to-skin care without separation of the newborn and woman after birth increases exclusive breastfeeding rates (Bramson et al., 2010; Crenshaw, 2014). In response to evidence that neonatal health outcomes are improved when newborns and their mothers stay together (Bhutta, Khan, Salat, Raza, & Ara, 2004; Erdeve et al., 2008; Levin, 1994), a new model of care, known as family care, has been developed (Örtenstrand et al., 2010). In the family care model, nurses and other clinicians care for neonates and their mothers together in a family care suite. The family is encouraged to stay and be coached to be the newborn’s primary caregivers. This care model provides for SSC and nonseparation of the family unit, especially just after birth; care by parents early in the hospital stay; and coaching for parents to be the primary caregivers of their newborns. This model has been shown to decrease LOS and lower risk for morbidities for newborns at greater risk (Örtenstrand et al., 2010). The compelling benefits associated with this model of care motivated clinicians at our hospital to build our new Special Care Nursery (SCN) with a design that would specifically facilitate this family care model. In this article we review the evidence for family care and describe how this model of care was planned and implemented at our institution. We also discuss the experience, lessons learned, and suggestions for future research. Abstract: Neonatal units are becoming more family-centered based on evidence of improved health outcomes when parents provide care to newborns. Physical environment constraints, as well as nursing care traditions and practices, have been barriers to providing care that includes close parental involvement. Our hospital’s experience in implementing a unique model of family-centered care in a Level II nursery suggests that this model of care is beneficial to families, satisfying to health care providers, and a viable model for practice. Some basic outcome data are discussed along with suggestions for future research. http://dx.doi.org/10.1016/j.nwh.2016.01.007 Keywords: family-integrated care | models of care | neonatal | NICU | skin-to-skin
Historical Perspectives on Neonatal Care Neonatal nursing units in the United States, designed to care for newborns requiring specialized care, have evolved over time. In the early 1900s, physicians believed that the best way of providing care entailed keeping parents out because of concern that these fragile newborns were vulnerable to infection and stress (Thomas, 2008). Parents were not allowed to touch their newborns, and families could view them only through a glass window (Thomas, 2008). By the 1960s, 80% of births were occurring in the hospital as opposed to in the family home, obstetrics had become a prominent specialty, and many newborn nurseries in hospitals were established (Thomas, 2008). Small “premie” nurseries from the 1960s grew during the 1970s and 1980s into
for healthy, full-term newborns throughout the United States. The couplet care model is supported by studies in which researchers show that early SSC, initiated ideally at birth, is associated with greater rates of breastfeeding and exclusive breastfeeding, increased breastfeeding duration, increased glucose levels within the first few hours after birth for full-term infants, and improved cardiovascular stability for late preterm infants (Bramson et al., 2010; Moore, Anderson, Bergman, & Dowswell, 2012). However, it is not only full-term and late preterm infants who benefit from close proximity to their parents. Authors of studies on KMC for preterm infants show that KMC is associated with a reduction in mortality at discharge or at 40 to 41 weeks postconceptual age, infection, hypothermia, and
large open units filled with incubators, bright lights, and noise from the addition of new medical equipment for monitoring, ventilating, and warming newborns (White & Newbold, 1995). By the 1990s, clinicians began to recognize the need for a less toxic environment that would foster development and healing by diminishing stimulation (White & Newbold, 1995). In addition, advances in developmental care of hospitalized preterm infants during the 1980s and 1990s began to emphasize the importance of parents’ participation in care (Thomas, 2008). Some NICUs began to offer space for parents to roomin, which was already the norm for well-newborn and pediatric wards (White & Newbold, 1995). With continually emerging data on KMC, SSC, and care by parent, neonatal caregivers are realizing that the optimal environment for premature infants is in close physical contact with parents (Bhutta et al., 2004; Conde-Agudelo et al., 2011; CondeAgudelo & Díaz-Rossello, 2014; Erdeve et al., 2008; Lawn et al., 2010; Levin, 1994). This paradigm shift necessitates a change in both the physical environment and the model of care provided to newborns requiring specialized care early in life.
Evidence for the Family Care Model Labor, delivery, recovery, and postpartum (LDRP) units have also evolved over the years. Couplet care, when women and newborns are cared for together, is now the standard of care Donna Mann, MSN, is a neonatal nurse practitioner at Catholic Medical Center in Manchester, NH. The author reports no conflicts of interest or relevant financial relationships. Address correspondence to: donna@ mannclan.us.
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length of hospital stay (Conde-Agudelo et al., 2011). KMC is also associated with increased weight gain, exclusive breastfeeding, or any breastfeeding at discharge and at further followup (Conde-Agudelo et al., 2011). Researchers in the field of epigenetics have provided evidence in rodent models that care by parent, especially within the first week of life, is actually associated with changes in DNA methylation, leading to expression of different genes and behaviors (Kaffman & Meaney, 2007; Szyf, Weaver, & Meaney, 2007). Perhaps these results may be found for human newborns as well, suggesting that the early environment for human infants may also influence DNA and gene expression. This would further strengthen the evidence for keeping parents and newborns together. Authors of an article reviewing research related to epigenetics and family-centered care report that although there are limited epigenetic studies on human newborns, inferences can be made that long-term epigenetic adaptations related to environment occur in preterm infants similar to those observed in animals (Samra, McGrath, Wehbe, & Clapper, 2012). Authors of a study of preterm infants born before 28 weeks gestation who were given a newborn individualized developmental care and assessment program, initiated by 72 hours of life and continued for 2 weeks, found that the infants had significantly improved neurobehavioral function at 2 weeks that continued to 9 months. The infants who received developmental care provided by both nurses and parents were better able to self-regulate and had improved state stability and threshold of responsiveness. They also had changes in electroencephalogram results consistent with improved motor organization, symmetry, and expression of attention (Als et al., 2004).
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Opening photo © Colleen Ellse, Background photo © Banana Stock / thinkstockphotos.com
THE COMPELLING BENEFITS ASSOCIATED WITH THIS MODEL OF CARE MOTIVATED CLINICIANS AT OUR HOSPITAL TO BUILD OUR NEW SPECIAL CARE NURSERY (SCN) WITH A DESIGN THAT WOULD SPECIFICALLY FACILITATE THIS FAMILY CARE MODEL
Photo © Colleen Ellse
Another population of infants at risk for complications is late preterm infants (34–36 weeks gestation). Late preterm births account for 75% of all preterm births. Compared with full-term infants, these infants are more susceptible to early morbidities and long-term developmental problems, including greater rates of respiratory distress, apnea, transient tachypnea, hypoglycemia, hypothermia, hyperbilirubinemia, seizures, and feeding problems. In addition, late preterm infants are 3 times more likely to develop cerebral palsy, have a 24% increased chance of reading scores below average in first grade, and are at increased risk for other developmental delays and the need for special education than children born at term gestation (Arpino et al., 2010). Authors of recent studies on infants born at 37 to 38 weeks gestation have shown that these newborns have greater incidences of hypoglycemia, need for respiratory support, need for intravenous fluids, and need for intravenous antibiotics, leading to increased admissions to special care units, than their full-term counterparts (Ghartey et al., 2012; Mally, Agathis, & Bailey, 2015; Parikh et al., 2014; Sengupta et al., 2013). Infants born late preterm and early term are also at increased risk for asthma and bronchitis during early childhood up to age 5 years compared with full-term infants (Odibo et al., 2016). The benefits of family-centered care and family-integrated care models for both full-term and late preterm infants are compelling. The evidence supports incorporating the family
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into the everyday care of the newborn. Many neonatal units now have single rooms, and parents are encouraged to stay to be their infant’s primary caregiver, with the support of the nursery staff. Evidence of benefits have been seen in Pakistan, where Bhutta et al. (2004) showed that recovering preterm infants whose mothers provided care in the hospital had decreased LOS and no increase in mortality or readmission. Wataker, Meberg, and Nestaas (2012) reported that in Norway, mothers residing with and providing care for their preterm infants 24 hours per day had higher confidence levels in caring for their infants and improved maintenance of breastfeeding after discharge. In Sweden, the family care model, with at least one parent caring for an infant born between 27 and 37 weeks gestation, led to decreased LOS and reduced risk of bronchopulmonary dysplasia (Örtenstrand et al., 2010).
Planning and Implementing the Family Care Model Family-centered care, care by parent, and parents rooming-in 24 hours per day with their infants have been shown to provide developmentally nurturing care and were the inspiration for the design of a new SCN at Catholic Medical Center in Manchester, NH. Modeled after the successful Karolinska units in Sweden (Örtenstrand et al., 2010), the goal for the SCN was to take the family-centered care model to a new level and to
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the design could be incorporated into our new unit. In addition, she reached out to a group of parents who had previously given birth to infants needing some extra care at Catholic Medical Center. These parents participated in a dinner and focus group and shared which practices and experiences were barriers to family-centered care and rooming-in with their newborns, as well as which supported and promoted family care. Using information from the Swedish model and the feedback from our own families, our director began working with architects to design a unit to fit in the space allocated by the hospital. Our planners were excited and eager to inaugurate this model of care in a new Level II nursery. With the goal to minimize separation of the family as much as possible, the new unit was designed to have space for parents to stay and also for staff to be able to care for women during their first few postpartum days. The unit was designed to have four family care suites, where the family would go for special care of the infant and care of the woman together. These rooms have space and appropriate equipment to care for women and newborns, as well as a sleeper sofa for a second parent or support person to room-in with them. In addition, to meet the needs of families once a woman is discharged, the unit was also designed with four special care rooms that can house four families. These special care rooms are equipped to provide medical and nursing care for infants, with accommodations for families to stay 24 hours a day, 7 days a week. They include room for two
Photo © Government of Alberta / flickr.com
provide care for all newborns that minimizes, if not eliminates, separation of the family unit. The need for a Level II unit at Catholic Medical Center arose in conjunction with a new group of obstetricians and midwives wanting to move their birth service to our hospital and have higher level neonatal care available. This provided the essential impetus needed for building a new neonatal care unit. Initially, design ideas began with a very traditional model of care in mind. However, the soon-to-be medical director had recently visited the Karolinska units in Sweden where the family care model was being practiced, and he proposed this model of care for our new unit. At Karolinska, premature infants, with the exception of extremely-low-birth-weight infants, were being cared for in this family care model. The thing that most impressed him was how natural it was for these families to be there caring for their newborns. He experienced the care as feeling comfortable and noted that the unit was truly designed to welcome and support the families who were staying for long periods of time. A nearby hotel provided food service for the parents. Prepared meals were left in the refrigerator, and parents could heat them up when needed. There were very nice communal spaces for families to use as well, including a kitchen and dining area. The director of maternal–child services at Catholic Medical Center attended a developmental care conference describing the Swedish model (Örtenstrand et al., 2010) to explore how
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parents to sleep, a refrigerator for breast milk, and a TV. The unit is also equipped with a common area that includes kitchen amenities, a washer and dryer, and a playroom for siblings or space for additional family members to gather. Nursing and medical staff for the new family-integrated unit were recruited through advertising, open houses, and direct connections. Several of the special care nurses came from the already existing LDRP unit, and others came from a wide variety of Level II and Level III units, mostly in the New England area. Because this model of care was totally new to the United States and staff came from varied backgrounds, it was important to put together a comprehensive orientation program. A key part of the orientation included a focus on the benefits of family care and the science behind this new model. Orientation also included information on how to operationalize this unique model on a day-to-day basis. In addition, nurses coming from the LDRP unit needed training in more advanced neonatal skills. Because the unit was not yet open, this training included didactic classes and observation time at a Level III unit associated with the hospital. Didactic classes on higher-level care of newborns included respiratory support, fluid management, and many other issues related to prematurity. Originally, the LDRP nurses were going to come to the family care suites to provide care for women, and the SCN nurses would care for high-risk newborns only. Over time, it became apparent that having the same nurse for the whole family would better support the family care model and allow for smoother workflow. The SCN nurses were then provided with education in the care of postpartum women, and they received clinical orientation on the LDRP unit.
Minimizing Separation of Women, Newborns, and Families Not only was the physical environment designed to minimize separation, but other aspects of care were considered as well. A respiratory device we named the “bridge” was created to allow a newborn with mild respiratory distress to stay in the labor room during the initial postpartum recovery period. Our “bridge” consists of a continuous positive airway pressure (CPAP) machine set up on a portable pole with oxygen and air tanks. This allows a newborn having respiratory distress to be started on CPAP in the birthing room, to be cared for by an SCN nurse, and to remain with the parents until the woman has recovered enough to be moved to the family care suite. Of course, safety is never compromised to keep everyone together. If a newborn is no longer stable, other interventions are provided as needed. These may include intubation, mechanical ventilation, placement of umbilical lines, and other necessary procedures. As much as possible, procedures are performed in the family’s room to minimize separation. Intravenous line placement and laboratory work are generally done
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OVER TIME, IT BECAME APPARENT THAT HAVING THE SAME NURSE FOR THE WHOLE FAMILY WOULD BETTER SUPPORT THE FAMILY CARE MODEL AND ALLOW FOR SMOOTHER WORKFLOW while the newborn is skin to skin to minimize separation and pain for the newborn. Minimizing separation of women and newborns requires nurses from both units to be flexible and help with assignments so that the new family can be cared for without separation whenever possible. The SCN nursery staffing is adjusted to allow the SCN nurse to stay in the birthing room until the mother has recovered from birth and the family is able to go to the family care suites together. The LDRP unit staffing is also sometimes adjusted to have labor and delivery nurses care for a woman in the family care suite if she requires more specialized maternity care than is feasible for SCN staff. Nursing staff are trained to be able to float between units as necessary as well.
Challenges and Lessons Learned With any change, once the new idea has been set in motion, it is necessary for staff to transition to a new way of thinking (Shirey, 2013). Couplet care is new for nurses experienced in caring only for newborns and not their mothers. In addition, family care requires SCN staff to give up control of many things they are accustomed to managing themselves. With a move toward empowering the family to have control and be the main caregivers, nurses perform more of a coaching role than their more traditional “doing” role. Traditions such as taking the newborn out of the room for different procedures or to give the family a break are replaced by all care being provided in the room with parents present. These changes have sometimes required staff to remind and encourage each other to continue to provide care with minimal separation, review progress at team meetings, and strategize together to meet the needs of both nurses and families. One challenge we have encountered is caring for women too ill to be adequately cared for in the family care suites. For example, if a woman is still requiring magnesium sulfate for very high blood pressure, she remains on the LDRP unit with nurses skilled at high-risk maternity care. One solution to this challenge has been to have the newborn stay on the LDRP unit and use telemetry to monitor the newborn from the Level II
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BASED ON PATIENT SATISFACTION SURVEYS, THIS MODEL OF CARE IS VALUED BY PARENTS AND ENHANCES THEIR CONFIDENCE TO CARE FOR THEIR NEWBORNS AT DISCHARGE nursery until the mother is well enough to move to the family care suites. This is successful if the newborn is stable enough to be cared for on the LDRP unit and staffing of both units supports this care. In other situations, staffing or patient acuity does not allow for keeping the family together when a woman is acutely ill, and the newborn is cared for separately in the SCN. Fathers and other family members designated by the woman may care for the newborn until the woman is stable enough to be transferred to the family care suites. Other solutions are still being explored. Nurse staffing is another challenge we have encountered. If there are too few SCN nurses to have one remain in the LDRP room for 1 to 2 hours of postpartum recovery before the woman and high-risk newborn can be transferred to the family care suite together, the family may need to be separated briefly. Most of the time our goal of nonseparation can be achieved, but staffing can be a barrier to fully providing our model of care at times. Factors related to the families also play a role in successful implementation of this model of care. Social and economic factors for parents, such as work obligations, may not allow them time to room-in with their newborns. Unlike in Sweden, where the family care model was initiated, parents in the United States are not guaranteed paid maternity or paternity leave from their jobs. In addition, the responsibility to care for other children at home can also be a barrier to having parents stay and spend significant time with their newborn in the family care suites. Some parents are reluctant to stay with their newborns. This may be attributable to a lack of understanding of the benefits of their presence or because they do not support the family care concept. In our experience, some families merely need to be informed of the benefits. Others decline to room-in with their newborns even after education and encouragement. In this case, the care of the high-risk newborn becomes more similar to traditional SCN models, with nurses providing the majority of care. Our experience with families rooming-in 24/7 has also led us to create a good citizens contract that families are given and sign on admission. It spells out expectations very clearly so that both nursing staff and families have an agreement about behavior and rules at the time of admission. It is not meant to set a rigid tone, but we found it helpful for families to know expectations up front, including everything from visiting guidelines to acceptable clothing.
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Other challenges in the operation of this type of unit include trying to account for costs across separate nursing units. The nursing care of mothers now moved to the SCN unit needed to be accounted for and billed to payers using a separate cost center. Currently, all revenue for the woman’s care is credited to the LDRP unit. Lessons were learned with regard to planning and evaluating outcomes. As we discuss in the next section, we do not have many outcome data, and those that we have may not be all that helpful. It is always prudent to begin with the end in mind, but because of an expedited deadline for opening the unit, plans were not put in place to identify, track, or measure different indicators of success. We can now see that the percentage of newborns placed skin to skin at birth, amount of time spent skin to skin at birth and daily throughout their hospitalization, percentage of families who were eligible for nonseparated care at birth who actually received it, amount of time parents spend rooming-in, and amount of time parents are actively caring for their newborns would be important things to have recorded and followed. Breastfeeding outcomes were followed, but more detailed information on women’s intent related to each newborn, not just overall percentages, would also be helpful. Long-term data on breastfeeding, meeting of developmental milestones, and parent confidence levels after discharge would also be useful items to measure. Identifying a comparison group of similar newborns with similar diagnoses and gestational ages receiving standard care might also be helpful in measuring success.
Outcomes With four family care suites, four special care rooms that can be doubled up if needed, and room in an observation area, the unit has 13 beds available and has had an average daily census of 7 to 8 over the past several years. The primary diagnosis from 2010 through 2014 was prematurity, accounting for 57% of admissions. Based on patient satisfaction surveys, this model of care is valued by parents and enhances their confidence to care for their newborns at discharge. Although the average LOS for high-risk newborns varies based on many factors, we suspect that this model of care has shortened the LOS or at least allowed for discharge at earlier adjusted postconceptual ages. We know that LOS is valuable in terms of cost savings, but we do not know if LOS is really a measure of success for our new model of care. Perhaps long-term follow-up data
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With regard to effects on breastfeeding, our data from 2014 show that 24.5% of our special care newborns were exclusively breastfeeding at discharge; 83% went home receiving a combination of breast milk and formula feedings. Only 17% were discharged with full formula-feeding. Staff response to this model has been overwhelmingly positive. As a health care provider, I find it rewarding to see families together from birth to discharge. Nurses and other members of the health care team have expressed that it is satisfying to send premature newborns home exclusively breastfeeding.
Photo © Ali Barton
Implications for Future Research
would be a better measure. We do not have the ability to compare data because there was only a Level I nursery at Catholic Medical Center before the opening of the SCN. Data on LOS specific to late preterm infants are minimal. We found one report by the March of Dimes (2011) reviewing data from 2009 and 2010 in which authors reported an overall LOS of 13.2 days. This is difficult to interpret because of the inability to compare populations. Interestingly, though, our data from 2010 show an overall average LOS of 13.2 days as well. In later years our overall LOS has increased, but our number of admissions from tertiary care centers has also increased, with extremely preterm infants coming to our unit to convalesce. Our data from 2014 show that for neonates born between 32 and 35 weeks (n = 27), the average postconceptual age at discharge from our SCN was 36 3/7 weeks. For newborns born between 26 3/7 and 35 weeks gestation that were transferred to us for continuing care from a Level III unit (n = 30), the average age at discharge was 37 weeks postconceptual age.
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Based on the past 5 years of experience since the unit was opened, both patients and staff consider this model to be beneficial to the family unit and one that should be continued. Outcomes for our infants with regard to breastfeeding, bonding, and age at discharge appear to be positive. Other research questions have emerged that will form the basis for ongoing and future data collection and help confirm the benefits of this model of care. Going forward we would like to determine if there is a correlation between breastfeeding and the following factors: amount of time spent skin to skin at birth, amount of time spent skin to skin throughout the hospital stay, and amount of time parents are rooming-in. We would particularly like to measure exclusive breastfeeding at discharge and longer-term breastfeeding data. In addition, it may be important to determine if parents’ time spent not simply in the room but actively providing care and/or being skin to skin with newborns is significant to these outcomes. Developmental outcomes should also be considered; infants will need to be followed up as outpatients to look at timing of developmental milestones or delays. The development of this unit has been challenging and rewarding for our hospital, and it appears to be of benefit to highrisk newborns and their families. Further research on LOS, feeding and developmental outcomes, cost, and staff satisfaction is warranted for our unit and for other units that are initiating this family-integrated model. Multisite studies and those with diverse populations of high-risk newborns could provide evidence that is needed to support development of units that a have family-integrated care model. We anticipate and encourage the development of similar units in other locations. NWH
Acknowledgment Thanks to all the nursing staff and health care providers of the Mom’s Place and Special Care Nursery, whose leadership, work,
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and collaboration help keep mothers and babies together, with special thanks to William Edwards, MD; Brenda Neff, RN, MSN, NE-BC; and Nicole Perdue-Pendenza, RN, BSN, RNCNIC. Thanks also to Deborah McCarter-Spaulding, PhD, RNC, for her encouragement and editorial guidance on this manuscript before its submission for publication.
implications of molecular insights. Journal of Child Psychology and Psychiatry, 48(3-4), 224–244. Lawn, J. E., Mwansa-Kambafwile, J., Horta, B. L., Barros, F. C., & Cousens, S. (2010). “Kangaroo mother care” to prevent neonatal deaths due to preterm birth complications. International Journal of Epidemiology, 39(suppl. 1), il44–il54. doi:10.1093/ije/dyq031 Levin, A. (1994). The Mother-Infant unit at Tallinn Children’s Hospital, Estonia: A truly baby-friendly unit. Birth, 21(1), 39–44. doi:10.1111/j.1523-536X.1994.tb00914.x
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