(~) Longman Group "'" ' " UK Ltd 1991

Midwifery

Rooming-in at night in the postpartum ward

Ulla Waldenstr6m and Asa Swenson
o

Since the early 1970s it has been c o m m o n practice for 'rooming-in' to take place d u r i n g the day in Swedish maternity wards. At night newborn babies are usually looked after by nursing staff in special nurseries. One reason for this is to avoid disturbing the mothers' sleep at night. T o promote m o t h e r - i n f a n t adaptation, we u n d e r t o o k a p r o g r a m m e i n t e n d e d to encourage night-time rooming-in. Evaluation o f the p r o g r a m m e was carried out as a quasi-experiment, divided into a pretest period (I), a 6-month implementation period, and a post-test period (II). Breast feeding and maternal sleep were studied d u r i n g the first 3 p o s t p a r t u m days by means o f self-report by 104 mothers in Period I and 111 mothers in Period II. T h e n u m b e r of hours that the babies spent in the nursery decreased f r o m Period I to Period II, a difference that was most obvious d u r i n g the second a n d third postpartum nights. No difference was f o u n d in the n u m b e r of breast feeds in Periods I and II, except d u r i n g the third night, when Period II mothers breast fed m o r e often. In spite o f increased rooming-in in Period II, these mothers slept the same n u m b e r o f hours a n d felt equally alert as Period I mothers.

INTRODUCTION
When, at the beginning of the present century, Swedish women began to give birth in hospital, postpartum care was also institutionalised. Attitudes to maternity care were greatly influenced by the way sick patients were cared for. The mother was confined to her bed, there was a long

Ulla Waldenstrom RNM, Dr med sci, Researcher and project leader, Birth Centre, ABC-enheten, Kvinnokliniken, S6dersjukhuset, S-100 64 Stockholm, Sweden. Asa Swenson RN, Director, S~itra Health Centre, Sicksackv~gen 34, S-803 33 G~ivle, Sweden. Manuscript accepted 15 January 1991 Requestsfor offprints to UW

lying-in period, the staff took over responsibility for both mother and baby and the father was excluded from all contact with his offspring. Since that time, the emphasis in maternity care has been shifted toward health care, i.e. childbirth is increasingly regarded as a healthy rather than morbid condition. Parents now take far more responsibility for the event. Mothers are choosing the position, such as sitting, standing, and kneeling, they feel most comfortable for the work of giving birth. The mother takes a greater responsibility for her baby and the father can more informally visit the mother and baby during the day-time. Early hospital discharge is becoming a common alternative. The usual routine regarding the care of newborn babies in hospital has until recently been

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83

that nursery nurses* take care of the babies in a special nursery on the maternity ward. From the early 1970s, babies began rooming-in with their mother during the day and in the evening. This change in hospital routine was an important prerequisite for breast feeding on d e m a n d and to enhance early mother-infant relationships. However, newborn babies still spend most of the night in the nursery. Until the early 1980s they were usually bottle fed at night by the nursery nurses. T h e y could be given breast milk f r o m their own mother or perhaps f r o m another mother, or even artificial milk. T h e routine of not breast feeding at night was changed dramatically in 1987 by a Medical Statute from the National Board of Health (1987) which restricted the use of breast milk f r o m surrogate mothers because of the risk of H I V infection. T h e usual routine nowadays is that the nursery nurse wakes the mother when the baby is hungry at night. T h e mother then usually takes her baby to another room to feed her/him so as not to disturb other mothers sleeping in the same room. T h e r e are many possible reasons for keeping newborn babies in a special nursery on the maternity ward. This has been the usual pattern of care since the institutionalisation of childbirth. It is asserted, but not scientifically supported, that nursery care guarantees better supervision of the baby. Ball (1989) found that rooming-in at night led to loss of maternal sleep. Filshie et al (1981) found that m a n y mothers (41%) who roomed-in with their baby at night were disturbed, not so much by their own baby, but by other mothers' babies. Nursery nurses may also experience difficulties in modifying their professional role, f r o m taking care of babies, to assisting mothers in how to look after their own baby (Cox, 1974). Knowledge of the ability of the newborn baby and the importance of contacts between mother

* N u r s e r y n u r s e s in Sweden have a m u c h s h o r t e r t r a i n i n g t h a n registered n u r s e s or midwives, a b o u t 1 year, c o n c e n t r a t e d on t h e care o f n e w b o r n babies. Maternity wards are usually staffed by midwives, registered n u r s e s in cases o f s h o r t a g e o f midwives, a n d n u r s e r y n u r s e s in the special n u r s e r i e s for t h e babies.

and baby are arguments against separating the two, unless it is necessary for medical reasons. A newborn baby is far more capable of interacting with her/his m o t h e r - - and other p e r s o n s - - than was earlier believed. T o d a y we know that newborn babies can see (Carpenter, 1975; Macfarlane, 1977), hear (Dworetzky, 1981; Rosenthal, 1982), smell (Macfarlane, 1977), taste (Crook & Lipsitt, 1976) and even imitate adult facial expressions (Meltzoff & Moore, 1983; Kugiumutzakis, 1985). In the light of this knowledge one can question whether the nursery is a better setting for the baby's first days of life than its own mother's room. Reefe (1987) demonstrated greater light and sound levels at night in a nursery setting than in the mother's postpartum room. In the same study she found that when babies slept in their mother's r o o m they had a significantly more quiet sleep and cried less than babies who remained in the nursery at night. Another study has shown (Martin & Russell, 1982) that newborn babies seem to be more disturbed by the crying o f other newborn babies than by the sounds f r o m older babies. Studies of early contact between mother and baby after birth have demonstrated beneficial effects on mother-infant interaction (Klaus et al, 1972; De Chateau, 1977), and also on breast feeding (Sosa et al, 1976; Elander and Lindberg, 1984). These investigations were based on extended contact during the day. By arranging for rooming-in day and night, the possibility of constant interaction and of satisfying the baby's needs might be still further improved. One of the main arguments for keeping newborn babies in special nurseries, the threat of disturbing maternal sleep, has been questioned by Keefe (1988). She found that mothers slept neither longer nor better when their baby was returned to the nursery during the night. Because of limitations of her study, such as the small sample size, the findings are difficult to generalise and she recomn~ended that there should be more research in this area. Regarding a revaluation of the objectives of maternity care in a Swedish hospital, the importance of mother-infant adaptation was stressed, and the routine practice of keeping all newborn babies in the nursery at night was questioned. A

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p r o g r a m m e aimed at encouraging rooming-in at night was adopted with the following content: 1. a one-day seminar for all nurses working in postpartum care, presenting the arguments for rooming-in at night, and with discussion o f potential impediments to change in existing routines; 2. an information folder for all p r e g n a n t women in the district, to encourage rooming-in at night during the p o s t p a r t u m stay in hospital; 3. contact with the local daily newspaper in order to present the new policy - - to stimulate mothers to take care of their baby even during the night; 4. rebuilding of 4 of the 16 four-bed rooms on the three postpartum wards at the hospital into 8 double-rooms. In order to evaluate the p r o g r a m m e an investigation with a pre-test period (Period I) followed by implementation of the p r o g r a m m e and a post-test period (Period II) was conducted. T h e hypotheses of the study were: Babies spend more time in the nursery in Period I than in Period II. - Fewer breast feeds are given in Period I than in Period II. - Mothers' pattern o f sleep is the same in Period I as in Period II.
-

METHODS
A quasi-experimental investigation divided into pre-test, intervention and post-test periods was conducted. During the first 3 weeks of October 1988 (Period I) all women delivered (148) at the University Hospital of Uppsala were given a diary on coming to the postnatal ward about 2 h after delivery. During the subsequent 6 months the p r o g r a m m e intended to encourage rooming-in at night was put into operation. In April 1989 (Period II) a further 150 w o m e n were asked to fill in the same kind of diary as given to w o m e n in Period I. Intervention was of two kinds: favourably

influencing attitudes to rooming-in at night (points 1, 2, and 3) and rebuilding of hospital rooms in order to facilitate rooming-in (point 4). T h e local newspaper published an article on the front page with approximately the same content as the leaflet given to the p r e g n a n t women. Mothers were shown, by a midwife or an obstetric nurse, how to fill in the diary every day, before retiring for the night. T h e y were asked to indicate by drawing a line on a time axis the length of time they had their baby in the nursery during the preceding 24h, and the n u m b e r of hours they had slept or dozed. T h e y assessed their personal feeling of fatigue or alertness by using a visual analogue scale. T h e mothers were also asked to state the n u m b e r of breast feeds given during the preceding 24h. They were informed that the purpose o f the study was to investigate breast feeding and maternal sleep during their p o s t p a r t u m stay in hospital. Demographic and obstetric data were collected f r o m the hospital records. In order to obtain a sample o f women who had given birth normally to a healthy baby, women who had undergone caesarean section and women whose baby was r e f e r r e d to the neonatal unit were excluded f r o m the final analysis (Period I: 1 + 23 women; Period II: 6 + 12 women). During the first period, 104 of the 124 women completed the diary (84%), and during the second period, 111 of 132 women (84%). T h e analysis included the first 3 postpartum days, which were defined as follows: 'Day 1' f r o m birth to 24h, 'Day 2', 2 5 - 4 8 h and 'Day 3', 49-72h. T h e response rate was best on the second postpartum day. T h e lower response rate on the first day was attributed to the fact that mothers who gave birth during the night were not given the diary on arrival in the ward, but on the following morning, and some of these mothers failed to report events of the first night. T h e lower r e s p o n s e rate on the third day was caused by some mothers' early discharge f r o m hospital. In order to study differences between day and night, day-time was defined as 6 a m to 10pm, and night-time as 10pm to 6am. T h e statistical tests used in the study were X 2 and Student's t-test.

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FINDINGS
T h e w o m e n in the two g r o u p s for Period I and Period I I did not differ significantly r e g a r d i n g profession, civil status or p r o p o r t i o n o f nonsmokers (Table 1). T h e second g r o u p , however, included slightly older women. Table 2 shows that the two g r o u p s were very similar as regards

such obstetric b a c k g r o u n d . Only one statistically significant difference was found, m o r e syntocinon stimulation in Period II than Period I. T h e only d e m o n s t r a t e d difference p o s t p a r t u m was a shorter hospital stay in Period II. T h e n u m b e r s o f w o m e n having a single or a d o u b l e - r o o m d u r i n g the second p o s t p a r t u m day were 6 (6%) and 41 (37%) in Periods I and II respectively (X 2 = 30.9, ldf, p < 0.001).

Table 1 Background characteristics of w o m e n in Period I and Period II

Period I (n = 104) Age: m(range) Civil status = married/cohabiting: no.(%) Profession: Unskilled and semiskilled workers: no.(%) Skilled workers: no.(%) Assistant non-manual employees: no.(%) Intermediate non-manual employees: no.(%) Employed and self-employed professionals, higher civil servants and executives: no.(%) Self-employed: no.(%) Non-smokers: no.(%) 27.6 (19-40) 97 (94) 22 19 13 25 (23) (20) (14) (26)

Period II (n = 111 29.0 (24-40) 106 (96) 15 17 17 28 (15) (17) (17) (28)

p t = 2.0; p < 0.05 NS NS NS NS NS NS NS NS

15 (16) 2 (2) 82 (79)

18 (18) 6 (6) 90 (83)

Table 2 Obstetric background of w o m e n in Period I and Period II

Period I (n = 104) Parity = primiparae: no.(%) Gestational age, weeks: m Labour and delivery: Length of labour in hours: m Obstetric analgesia Pethidine: no.(%) Epidurah no.(%) Entonox: no.(%) Local: no.(%) Episiotomy: no.(%) Syntocinon: no.(%) Bleeding in mh m CTG-registration in hours: m Vacuum extraction: no.(%) Baby outcome: Baby weight in grams: m 5min Apgar: m Post partum: Maternal complications: no.(%) Mothers taking analgesics: no.(%) Mothers taking sleeping pills: no.(%) Postpartum stay in hospital, days: m 42 (40) 39.3 8.0 39 10 55 61 (38) (10) (53) (59)

Period II (n = 111) 41 (37) 39.5 6.7 37 7 66 72 (33) (6) (60) (65)

p NS NS NS NS NS NS NS NS X 2 (ldf) = 7.6, p < 0.01 NS NS NS NS NS NS NS NS t = 2.4, p < 0.02

17 (16) 9 (9) 335 2.3 1 (1) 3610 9.9 9 (9) 53 (51) 5 (5) 4.4

24 (22) 25 (23) 310 2.4 4 (4) 3631 9.8 6 (5) 54 (49) 5 (5) 3.9

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MIDWIFERY 4. No differences were detected during the daytime or during the first 2 p o s t p a r t u m nights. During the third night, however, mothers in Period I I breast f.. :1 more often than Period I mothers, though this difference was not reflec, ted in the breast feeding rates for day and night when analysed together. Possibly the breast feeding pattern changed between day and night so that babies sleeping close to their mother were breast fed more often during the night and correspondingly less during the day.

Time in the nursery

During the day-time, the 16h between 6 a m and 10 pm, the babies spent about the same n u m b e r of hours in the nursery in Period i as in Period II, an expected finding (Table 3). During the night (the 8h between 1 0 p m and 6am) babies spent more time in the nursery in Period I than in Period II, except for the first night after the birth. T h e differences were still statistically significant when day and night figures were combined, which gave an average difference of about 1.5 h for the second and third days. T h e r e was a general tendency for mothers in both groups to leave their baby for shorter times in the nursery with each day that passed.

Sleeping patterns
T h e mothers slept about the same n u m b e r of hours in Period I as in Period II (Table 5). T h e y dozed more during the day-time in Period I, a fact that was reflected in statistical differences even when day and night were analysed together

Breast feeding
T h e numbers of breast feeds are shown in Table

Table 3 Babies' stay in the nursery, expressed as the average number of hours (m) and per cent (%) of the day-time, night-time and day + night during the first, second and third days postpartum
Part of the day Postpartum day 1 2 3 1 2 3 1 2 3 Period I m 2.8 2.6 2.1 5.6 5,3 4.7 8.1 7.9 6.9 % 18 16 13 70 66 59 34 33 29 (n) (93) (101) (96) (67) (103) (99) (67) (101) (96) Period II rn 2.7 2.2 2.0 6.2 4.1 3.6 8.7 6.3 5.6 % 17 14 13 78 51 45 36 26 23 (n) (89) (103) (91) (72) (103) (96) (71) (103) (91) p NS NS NS NS t = 3.1, p < 0.01 t = 2.8, p < 0.01 NS t = 3.4, p < 0.001 t = 2.5, p < 0.02

Day-time:
6am-10pm (16h)

Night-time:
10pm-6am (8h) Day and night (24h)

Table 4 Number of breast feedings (mean) day-time, night-time, and day + night during the first, second and third days postpartum
Part of the day Postpa rtu m day 1 2 3 1 2 3 1 2 3 Period I m 3.8 4.9 5.8 0.5 1.2 1.5 4.4 6.0 7.2 (n) (93) (101) (96) (67) (103) (99) (67) (101) (96) Period II m 3.9 4.5 5.4 0.6 1.2 1.8 4.6 5.8 7.2 (n) (90) (103) (93) (73) (103) (98) (72) (103) (93) p NS NS NS NS NS t = 2.1,p < 0.05 NS NS NS

Day-time:
6am-10pm (16h) Night-time: 10pm-6am (8h) Day and

night
(24h)

MIDWIFERY 87
Table 5 Maternal sleep expressed as the mean number of hours (m) day-time, night-time, and day+night during the first, second and third days postpartum. Period I m 1.0 0.9 1.1 3.7 4.7 4.6 4.6 5.7 5.7 (n) (93) (101) (96) (67) (103) (99) (67) (101) (96) Period II m 1.2 0.9 0.9 4.1 4.5 4.6 5.1 5.4 5.6 (n) (89) (103) (91) (72) (103) (96) (71) (103) (91) p NS NS NS NS NS NS NS NS NS

Part of the day Day-time: 6am-10pm (16 h) Night-time: 10pm-6am (8 h) Day and night (24h)

Postpartum day 1 2 3 1 2 3 1 2 3

Table 6 Maternal dozing expressed as the mean number of hours (m) day-time, night-time, and day+night during the first, second and third days postpartum Part of the day Day-time: 6am-10pm (16h) Night-time: 10pm-6am (8 h) Day and night (24h) Postpa rtu m day 1 2 3 1 2 3 1 2 3 Period I m 2.1 2.0 1.7 1.3 0.8 0.4 3.4 2.8 2.1 (n) (93) (101) (96) (67) (103) (99) (67) (101) (96) Period II m 1.7 1.4 1.1 1.2 0.6 0.5 2.9 2.0 1.5 (n) (89) (103) (91) (72) (103) (96) (71) (103) (91) p NS t = 2.7, p < 0.01 t = 2.4, p < 0.02 NS NS NS NS t = 2.5, p < 0.02 t = 2.1, p < 0.05

Table 7 Mothers' experiences of fatigue-alertness during the first, second and third days postpartum, expressed as the mean value on a visual analogue scale, analysed as a 7-point scale with 1 = very tired, 3 = neither/nor, 7 = very alert Period I Postpartum day 1 2 3 m 3.4 4.4 4.7 (n) (94) (103) (100) Period II m 4.0 4.5 4.6 (n) (99) (105) (101) p t = 2.5, p < 0.01 NS NS

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(Table 6). However, this difference in dozing during the second and third day had no effect on the mothers' personal experience of fatigue. T h e y fehjust as alert in Period I as in Period II, except for the first postpartum day (Table 7).

DISCUSSION
T h e p r o g r a m m e appears to have influenced the clinical practice of rooming-in at night. Period I I mothers left their baby in the nursery for fewer hours than mothers in Period I. T h e r e is little reason to suspect any other explanation for this change in behaviour than the effects of the p r o g r a m m e . T h e groups of mothers c o m p a r e d had very similar backgrounds (Tables 1 and 2), and we could see no internal or external event occurring concurrently with the described interventions. Nevertheless, it cannot be entirely ruled out that the higher mean age in Period II may have had some impact on the findings. An analysis of all mothers in the study, irrespective of the time of data collection, showed that older mothers were less inclined to leave their baby in the nursery than were younger mothers. A corresponding analysis of mothers with and without syntocinon stimulation in labour indicate that the difference the syntocinon stimulation between the two groups did not affect the findings. No conclusion can be drawn regarding what factors had most impact on the mothers' behaviour - the influencing of attitudes, or the remodelling of the hospital rooms. Only 6% of the mothers had a single or double-room in Period I, compared with 37% in Period II, probably a difference of great importance for the findings. At the same time we believe that staff attitudes have a great impact on mothers' behaviour on the maternity ward. This impression may explain the findings for the first postpartum day. T h e babies spent 70% or m o r e of the first night in the nursery and no statistical difference was found between the two periods. This finding could reflect a reluctance on the part of the nursery nurses to entrust babies to the mothers. T h e main problem expressed by the nurses during the one-day seminars was their

anxiety over allowing mothers to take over the responsibility for their own baby during the first night after the delivery. Even though revised guidelines, which clearly stated that the babies could be with their mother f r o m the start, with extra supervision by the nurses during the first 6hours after the delivery, were formulated when starting the p r o g r a m m e , the nurses' earlier attitudes may still have affected maternal behaviour in practice. By sleeping close to their baby, we assumed that mothers would breast feed more often because of a greater sensitivity to the baby's signals than the nursery nurses may have had. This assumption was confirmed only during the third postpartum night, which may have been due to the fact that the third night was the night when mothers had their baby for the longest time, viz. 55% of the 8h. No difference was found between Period I and Period II regarding the n u m b e r of hours mothers slept, or concerning feelings of fatigue on the second and third p o s t p a r t u m days. These findings indicate that, with an increased access to single and d o u b l e rooms, rooming-in at night has no negative effect on maternal sleep. It is possible that mothers are less disturbed by their own baby, than by other conditions in the hospital environment, such as unusual noise and lights, other mother-infant couples in the same room, warding of newly delivered women in the middle of the night or by being woken too early in the morning (Filshie et al, 1981; Waldenstr6m, 1987). Bernal (1972) showed that 77 newborn babies delivered at h o m e had their peak of crying in the evening, between 6 pm and midnight, and not during the night, between midnight and 6am. Campbell (1986) found that mothers obtained as many hours of sleep during the first postpartum weeks as they did prior to pregnancy, but their sleep was subject to m a n y interruptions. This sleeping pattern is similar to the one found in the present study. T h e average n u m b e r of hours of good sleep was less than 6 per day. T h e mothers were then dozing for about another 2 hours, mostly during the day. T h e differences found in day-time dozing is possibly an effect of the time o f data collection,

MIDWIFERY 89 O c t o b e r (Period I), which is a very d a r k m o n t h in Sweden, whereas April (Period II) is m u c h lighter. U n f o r t u n a t e l y , we did n o t consider this source o f bias w h e n p l a n n i n g the study. T h e s h o r t e r hospital stay in Period II may have b e e n d u e to the fact that a b o u t 8 m o n t h s before the start of the p r e s e n t study domiciliary visits were i n t r o d u c e d as a n alternative for m o t h e r s choosing a n early hospital discharge. As it usually takes some time for a n e w o p t i o n to become accepted, it is possible that t h e r e was less interest in early discharge in Period I t h a n in Period II. However, the s h o r t e r hospital stay in Period II could equally he a n effect o f the p r o g r a m m e a n d the e x t e n d e d r o o m i n g - i n at night. By taking m o r e of the responsibility for their baby the m o t h e r s m a y have g a i n e d in confidence a n d felt less n e e d for hospital care. We agree with Ball (1989) that 2 4 h r o o m i n g in should be a n o p t i o n for p o s t p a r t u m mothers. However, it is n o t o u r e x p e r i e n c e that it is practised in a n ' i n d i s c r i m i n a t e m a n n e r ' . O u r e x p e r i e n c e suggests that the m a i n p r o b l e m is that all w o m e n who want to r o o m - i n with their baby do not have this o p p o r t u n i t y . D h a r a m r a j a n d colleagues (1981), for instance, not only f o u n d variations in w o m e n ' s p r e f e r e n c e s for r o o m i n g - i n , b u t also that m o r e m o t h e r s preferred r o o m i n g - i n t h a n t h e r e were available facilities. T h e hypotheses raised in this study were to a great e x t e n t s u p p o r t e d by the data, b u t f u r t h e r research is n e e d e d in o r d e r to draw valid conclusions r e g a r d i n g the effects o f n u r s e r y care o n breast f e e d i n g a n d m a t e r n a l sleep. T h e d i f f e r e n c e in r o o m i n g - i n at n i g h t b e t w e e n the two periods studied was small a n d the risk of c o n f o u n d i n g factors i n f l u e n c i n g the o u t c o m e can n e v e r be e x c l u d e d with a q u a s i - e x p e r i m e n t a l design. Midwives, research and childbirth, Vol 1, Chapman and Hall, London Bernal J 1972 Crying during the first 10 days of life and maternal responses. Developmental Medicine and Child Neorology 14:362-372 Campbell I 1986 Postpartum sleep patterns of motherbaby pairs. Midwifery 2:193-201 Carpenter G 1975 Mother's face and the newborn. In: Lewin R (ed) Child Alive. Temple Smith, London Cox B S 1974 Rooming-in. Nursing Times 70(32): 1246-7 Crook K, Lipsitt L P 1976 Neonatal nutritive sucking: effects of taste stimulation upon sucking rhythm and heart rate. Child Development 47:518-22 Dharamraj C, Sia C G, Kierney C Met al 1981 Observations on maternal preferences for rooming-in facilities. Pediatrics 67:638-40 De Chateau P 1977 The importance of the neonatal period for the development of synchrony in the mother-infant dyad - a review. Birth and the Family Journal 4:10-22 Dworetzky J P 1981 Introduction to child psychology. West Publishing Company, New York Elander G, Lindberg T 1984 Short mother-infant separation during first week of life influences the duration of breast feeding. Acta Paediatrica Scandinavica 73:237-240 Filshie S, WilliamsJ, Osbourn M, et al 1981. Post-natal care in hospital - time for change. International Journal of Nursing Studies 18(2): 89-95 Keefe M 1987 Comparison of neonatal night time sleepwake patterns in nursery versus rooming-in environments. Nursing Research 36:140-144 Keefe R M 1988 The impact of infant rooming-in on neonatal sleep at night. J Obstetric, Gyecologic & Neonatal Nursing 17:122-6 Klaus M H, Jerauld R, Kreger N C et al 1972 Maternal attachment: Importance of the first post-partum days. New England Journal of Medicine 284:460 Kugiumutzakis J 1985 Origin and the development of the early infant imitation. Doctoral thesis, Department of Psychology, University of Uppsala Macfarlane A 1977 The psychology of childbirth. Open Books Publishing Ltd London Martin G B, Russell D C 1982 Distress crying in neonates: species and peer specificity. Developmental Psychology 18:3 9 Medical Statute 1987: 22. National Board of Health and Welfare, Stockholm (in Swedish) Meltzoff A N, Moore K M 1983 Newborn infants imitate adult facial gestures. Child Development 54: 702-709 Rosenthal M K 1982 Vocal dialogues in the neonatal period. Developmental Psychology, 18:17-21 Sosa R, KennellJ H, Klaus Met al 1976 The effect of early mother-infant contact on breast feeding, infection and growth. In: Elliott K, Fitzsimons D W (eds) Ciba Foundation Symposium no. 45 (New Series) Amsterdam: Elsevier Waldenstr6m U 1987 Early discharge after hospital birth. Doctoral thesis. University Hospital, Uppsala, Sweden

Acknowledgements
This study was supported by the First of May Flower Annual Campaign for Childrens Health.

References
BallJ A 1989 Postnatal care and adjustment to motherhood. In: Robinson S & Thompson A M (eds).