The Development of Rooming-in at Yale *

The Development of Rooming-in at Yale * EDITH B. JACKSON The term "rooming-in" refers to "a hospital arrangement for maternity patients wherein a mother and her newborn are cared for together in the same unit of space. However, its meaning reaches beyond physical facilities and signifies an attitude in maternal and infant care and a general plan of supportive parental education which are based on the recognition and understanding of the needs of each mother, infant, and family. It is a plan to maintain natural mother-infant relationships, to reinforce the potentialities of each mother and infant, and to encourage the family unit. From this broad point of view, then, rooming-in is not to be viewed merely as a specific plan for space arrangement or as a particular kind of equipment or organization, but rather as an integrated, interdepartmental program of professional assistance which is aimed to help parents achieve happy family unity and warm parent-child relationships. Such a program is developed through physician counseling, nursing procedure, personnel assignment, and hospital arrangement which, though they may vary in detail, are all based on this broader, deeper concept of the meaning of rooming-in.""5 The foregoing statement defines the aims of the first rooming-in programns to be initiated in the United States. The definition was agreed upon in 1950 by representatives of medical centers in which rooming-in plans were in operation or in prospect. Active planning for rooming-in had begun in the early '40's at George Washington University,'7 in Detroit under the sponsorship of the Cornelian Corner,tu and at Yale University,'0 and interest was gradually extending to other institutions. The first scattered outcroppings of interest probably bore some relation to a series of interinstitutional and interdisciplinary meetings beginning in the late '30's concerning psychological aspects of child behavior and factors that favor or hinder healthy emotional development. Child care methodology thus came under review. Pediatric emphasis at that time was principally on regulations for physical care of children with little regard for psychological considerations. The selected group of child psychiatrists, psychologists, pediatricians, social scientists, and educators in these meetings shared the opinion that insistent strictness of routines in infant and child care played a role in the development of some of the emotional disturbances of childhood. * From the Departments of Pediatrics and Obstetrics and Gynecology, Yale University School of Medicine, the University Service of the Grace-New Haven Community Hospital, and the Yale University School of Nursing. t An interdisciplinary group formed to advance the interests of parent-child relationships. Received for publication May 11, 1953. Accordingly, attention was focused on ways of modifying child care practices in a less rigid direction. Stimulus for such modification appears to have come also from mothers who expressed to their pediatricians a strong wish to have the baby in a closer and more natural relationship than was allowed by the usual hospital maternity arrangements. In Washington, D. C., Mrs. Frances Simsarian appealed to Dr. Preston McLendon to facilitate hospital arrangements which would allow her to breast feed her baby in response to his hunger rather than the clock. The arrangements called for having mother and baby in the same room. They were sanctioned on the basis of permitting scientific observations of an infant's reaction on a "self-demand" schedule. The report of this "experiment" by Mrs. Simsarian and Dr. McLendon in itself' and in its subsequent influence17 documents the scientific introduction to hospital maternity rooming-in. At approximately the same time that Mrs. Simsarian was making her request, other mothers elsewhere were doing likewise. In New York, Dr. Margaret Mead asked Dr. Benjamin Spock's help in arranging for her newborn baby to be in the same room with her, and in New Haven Mrs. Joan Erickson asked for a similar arrangement through her obstetrician, Dr. Margaret Tyler, her family counselor, Dr. Marian C. Putnam,* and her husband, Erik Erickson, a Yale faculty member in the Department of Psychiatry. Although these two maternal requests were not the subject of official report, they were nonetheless influential. The difficulties these parents met in gaining permission for the desired hospital arrangements forcibly directed the attention of their professional associates to the disruptions of natural family relationships caused by rules and routines of hospital maternity care. One of these associates at Yale was Dr. Grover F. Powers, Chairman of the Department of Pediatrics. Dr. Powers, ever alert to ways of improving service to patients and their families, picked up the challenge for change in the pediatric approach to child guidance and for integration of the pediatric and obstetrical responsibilities in hospital maternity service. In a paper which appeared in this Journal fourteen years ago he stated: ... It may be appropriate to mention a matter which gives me concernthe interrelated responsibilities of obstetrician and pediatrician in the handling of mother and baby during the neonatal period. Many obstetricians turn over to the pediatrician the care of the newborn baby. I approve heartily of this procedure, but I am sure it is not entirely satisfactory at this time due to the fact that many pediatricians do not utilize the obstetricians' special knowledge of and relationship to the mother at this critical time. He very naturally has the special confidence of the mother of the baby he has just brought into the world.... The pediatrician too often comes into the situation almost a stranger. And yet, just at this time the adjust*Psychiatric consultant to the Department of Pediatrics. When Dr. Putnam left New Haven in 1939, the writer succeeded her in this interdepartmental relationship. ment between mother and new baby-one of the most delicate and critical either will ever have to face-has to be made. This adjustment cries out for complete co-operation and understanding between the two physicians and for a unified program as to management and maternal nursing. [And again] . . . Certain developments in pediatrics itself have had malignant influence upon the emotional life of children.... Rules and regulations have their proper place as rough guides against too flagrant a departure from the ordinary routines of life and conduct. But insistence upon fixed procedures without wide latitude for individual variation has brought upon many children emotional disorders which have manifested themselves in a variety of "body protests" and of other displays of neurotic behavior. Our strict therapy has often fostered some of the very disorders we were trying to prevent.t To implement the indicated changes, Dr. Powers sought ways of providing his Resident staff with opportunities and responsibilities in the supervision of well babies. With the co-operation of the city health officer, Dr. Joseph I. Linde, he was able in 1939 to introduce a home visiting plan for the nursery interne for the follow-up of clinic-status neonates. This plan had the dual aim of providing needed service for clinic mothers and realistic experience for pediatricians-in-training beyond the impersonal routines of the hospital.' Similarly, his associate, Dr. Herbert Miller, who was then physician-in-charge of the pediatric out-patient clinic and the newborn nursery, encouraged a more general use of the six-week check-up examination and the child health conference* to implement the individual approach in well baby care in the training program of staff and students. And periodically, during the early 1940's, Dr. Powers let fall the suggestion that rooming a baby together with his mother be tried. The freedom to make this suggestion had been given him by Dr. Arthur T. Morse, Chairman of the Department of Obstetrics and Gynecology. The fact that it was only in 1944 that the suggestion was first carried out may be largely explained by the shortage of hospital staff and the accelerated teaching programs during the war years. A theoretical description for "a rooming-in arrangement for the baby" had been made to the reading public in 1943 with the publication of Infant and Child in the Culture of Today by Dr. Arnold Gesell and Dr. Frances Ilg.5 The term, "rooming-in," thus came into general use, and the interest of many patients in New Haven and elsewhere was stimulated. The early attempts with rooming-in during 1944 and the summer of 1945 revealed definite interest in rooming-in among some parents and members of the hospital staff, and they pointed up the need for close interdepartmental co-ordination for future undertakings. To this end, Dr. Morse and Dr. Powers arranged for occasional joint meetings of the obstetric and newborn nursery staffs. In addition, the combination of events during the following years gradually effected a co-ordination of interest. City Department of Health in the pediatric out-patient clinic. Held by the Visiting Nurse Association of New Haven and the New Haven AC 0,11"'..I NL Dr. Alan Foord, Dr. Edith B. Jackson, and Dr. Herbert Thorns-three members of the Roonming-in Policy Committee. The snapshot was taken in October 1946 by Miss Elly James, a Swedish} newspaper reporter oIn a visit to the United States, who had come to New Haven to "look at the rooming-iin method" and report oIn it for her paper. In July 1945, Dr. Alan Foord became instructor in pediatrics and public health and physician-in-charge of the pediatric out-patient clinic, and the writer became physician-in-charge of the maternity nursery and the neonatal follow-up clinic.* They shared responsibility for furthering the program of teaching around the well baby services in the hospital. The general lack of enthusiasm of the hospital staff for this aspect of the work seemed due in part to a lack of continuity in their relationship to families. The home visiting plan for the nursery interne had been the first step in providing him with some continuity in experience, but the two-month period of rotation was too short. It had long been noted that the pediatrician was in the key position to make detailed observations of mother-child relationships and had special need to understand them. Accordingly, Dr. Powers suggested the initiation of a study in this field under the writer's supervision, with a pediatrician-in-training as a research assistant and the framework of the study so devised that it could both serve the interests of mothers and infants and provide training for the annually appointed pediatric assistant. When the initial formulations for such a study were made in the fall of 1945, it was hoped that it might become associated with and strengthen the development of rooming-in. However, the future of rooming-in at Yale was uncertain just then. Early in 1946 plans for a new building of the Grace-New Haven Community Hospital were getting underway. Dr. Albert W. Snoke had been appointed director of the hospital. The question was raised with him about the advisability of incorporating rooming-in arrangements in the architectural plans. His immediate reaction, with no prior knowledge of the background of the question, was adverse.t However, he allowed himself to be convinced that the question should be given further consideration. Dr. Powers, feeling perhaps that a good idea was seriously threatened, wrote in a letter to Mr. Robert S. Judd, Chairman of the Building Fund Committee, on March 1, 1946, as follows: . . . In any building operation, time always reveals that mistakes have been made. These are often unavoidable, but I am absolutely convinced that if we do not set up some units in the new hospital to meet the need of those mothers who wish to have their babies with them from birth on, we will be making a mistake in full knowledge at this time of the fact that we are making a mistake. The maternity unit should have great flexibility. ... Mothers in this community are definitely interested, and this interest is increasing. On March 4, 1946, Miss Kate Hyder came to Yale as the newly appointed nursing supervisor of the obstetric and gynecologic service and assistant professor of obstetric and gynecologic nursing. Four days later * Dr. Miller resigned to become chairman of the Department of Pediatrics at Kansas University School of Medicine. t Dr. Snoke has often quoted himself as saying, "That's as crazy an idea as I've ever heard!" the pediatric nursery staff were invited to join the obstetric staff at a tea meeting for an informal discussion of breast feeding, "self-demand," and rooming-in. Dr. Herbert Thoms, then associate professor of obstetrics and gynecology, was chairman. He gave enthusiastic support to the rooming-in idea. "Let's go!" he said. Miss Hyder expressed definite interest, but she asked for time to study the situation, knowing that the ultimate success of a rooming-in plan must depend on the adequacy and attitude of the nursing service. The decision for immediate plans on the maternity floor and for future plans in the new hospital building awaited Miss Hyder's conclusions. In the meantime (April, 1946) Dr. Powers made a request to Mead Johnson & Company for "a grant-in-aid in support of an investigation in mental hygiene as respects parents and neonates." He submitted a plan for a three-year study in the Department of Pediatrics and defined its aim as follows: The objective of this project is to obtain necessary knowledge for the guidance of parents in order to prevent or at least reduce the great number and variety of behavior problems and psychosomatic disorders in young children, some of which are nutritional in nature and often apparently have their inception in the early days or weeks of life. Physicians, especially obstetricians and pediatricians, are continually confronted with the necessity of giving concrete advice and direction to women, for which there is as yet little scientifically based knowledge for their guidance in the subtle but highly significant mental health aspects of infant care. We believe that a study of the interrelation between maternal attitudes and the development of behavior patterns in children will lead to a further understanding of the origin of certain behavior disorders and therefore to the possibility of their prevention. The requested budget was in support of a full-time special supervising nursing assistant or fellow, a full-time pediatric research assistant or fellow, and special nursing or other service necessary for acquiring and for recording data. Notification of the acceptance of this application was received in May. By this time Miss Hyder had reached the conclusion that rooming-in could not be successfully carried out in single rooms, but that it could be worked out in a unit with four mothers and babies with the existing quota of nursing personnel plus one additional graduate nurse to be in charge of the unit. Dr. Powers suggested the prospective Mead Johnson Nursing Fellow for this position. In this way the study plan became linked with the rooming-in program. The appointment of a full-time Mead Johnson Pediatric Fellow* for the ensuing academic year was made almost immediately to assist in the study and in the eventual rooming-in plan. In June 1946, the group of individuals most closely involved in the development of rooming-in met together in the writer's office to initiate * Dr. Edward Daniels, called to military service in August 1946, was replaced by the appointment of Dr. Richard W. Olmsted in September 1946. plans in accord with Miss Hyder's recommendations and Dr. Powers' suggestion. Those present were Dean Elizabeth Bixler of the Yale School of Nursing, Dr. Alan Foord,* Miss Kate Hyder, Dr. Grover Powers, Dr. Herbert Thoms, and the writer. (This group subsequently formed itself into the Rooming-in Policy Committee.) The first action was a request to Dr. Morse for permission to use the maternity ward solarium for roomingin. This was in the days before early ambulation and the solarium was actually little used except as overflow space during periods of high census. Permission was immediately granted. The request to remodel the solarium was then made to Dr. Snoke who had in the meantime, under the impact of the interdepartmental solidarity, become definitely interested in the possibilities of rooming-in and was willing to have it tried out as a hospital "experiment." In July, the necessary changes in the solarium were authorized. Dr. Martha L. Clifford, Director of the Bureau of Maternal and Child Hygiene of the Connecticut State Department of Health, helped with the plans for remodeling. While the conversion of the solarium was in progress (September and October), the first stages of the parent-child relationship study began to crystallize around plans for the rooming-in unit and the work of the pediatric fellow, Dr. Richard W. Olmsted. The latter was assigned responsibility for the care of the infants with their mothers in the unit and for observations for the study. Methodology for the recording of his initial observations were worked out by Dr. Ethelyn H. Klatskin,t Dr. Seymour Sarason,4 Dr. Powers, the writer, and Dr. Olmsted himself. It was planned that he should select mothers in prenatal clinic for rooming-in, that he should prepare the selected mothers for the "ad-lib" procedures of roomingin, and at the same time record his observations for the study regarding the mothers' attitudes and responses. He would then continue his dual role of pediatric adviser and observer in the rooming-in unit, where he would be assisted by the nursing fellow, and postnatally in home visits, neonatal clinic, and child health conference. Plans for the rooming-in unit and plans for the study were thus merged, and all aspects of the work were thought of as belonging to the development of a rooming-in program which offered continuity in counselling service for parents and in experience for the pediatric fellow. Everything connected with this program was labeled "roomingin." Accordingly, when the rooming-in unit was opened at the end of October 1946, "rooming-in mothers" were waiting for admission and were followed by the "rooming-in fellow" according to the "rooming-in pro* Community Hospital in April 1946. t Dr. Klatskin has been research assistant in pediatrics (psychology) since 1946, and is assistant professor of psychology. t Dr. Sarason was at the time psychologist at the Southbury Training School and assistant attending psychologist on the University Service of the Grace-New Haven Community Hospital. At present, he is associate professor of psychology at Yale. Dr. Foord had been appointed an assistant director of the Grace-New Haven gram" of study. Because of the joint framework of plans for the rooming-in unit and for the parent-child relationship study, the latter acquired the title "Rooming-In Project."* This identity in name gave rise to confusion as to the nature of the rooming-in "experiment" and encouraged the erroneous assumption that the research was directed toward proving the advantages of rooming-in over traditional methods of hospital maternity care. The early history of the cross-fertilization of clinical and study procedures relating to the roomingin unit has been reviewed in detail both to clarify this misunderstanding and to indicate the variety of influences which contributed to the vigor of rooming-in at Yale. The training opportunities of the program appealed to Dr. Powers so much that he assigned as many pediatric fellows of assistant resident rank as he thought it could absorb while data for the study were being collected. He appointed two fellows for the second year and three for each of the following three years.t One of the fellows, Dr. Morris A. Wessel, remained associated with the rooming-in program for three years.t Since the Rooming-In Project study,§ per se, is not the main theme of this paper, I shall continue with an outline of the development .of rooming-in on the University Service of the Grace-New Haven Community Hospital. There was unanimity about the over-all aims and procedures for the rooming-in unit.1' These may be summarized as follows: The room should be cheerful, comfortable, quiet, and homelike. There should be an adjacent night nursery for the infants to protect the mother's sleep against interruptions except for breast feeding. There should be a nurse available around the clock to meet the needs of both mothers and infants on a flexible schedule. Nurses and doctors assigned to rooming-in should have prior orientation as to the rationale of "ad-lib" methodology, and to management of breast feeding. Mothers should have prenatal orientation to hospital facilities and opportunity for prenatal discussion with the physician who would supervise the infant's care. Only mothers who wanted rooming-in should be assigned to the unit. Mothers might be admitted to the unit directly from the delivery room if there were an available bed; otherwise, in turn as rooming-in beds become available. Each mother should have the * The initial grant-in-aid from Mead Johnson & Company terminated in 1949. The Project has received short-term grants-in-aid from The George Davis Bivin Foundation, Inc., The Field Foundation, Inc., and a continuing grant from the National Institute of Mental Health of the National Institutes of Health, United States Public Health Service, for the five-year period 1948-1953. t The Fellows succeeding Dr. Olmsted were as follows: James A. Kleeman, Ruth I. Svibergson (1947-48); George R. Barnes, Jr., Anton N. Lethin, Jr., Morris A. Wessel (1948-49); John C. Cobb, Richard H. Granger, Sylvia N. Preston (1949-50); George S. Harris, Gordon Jensen, William L. Nyhan (1950-51). t Dr. Wessel was Fellow of the Dazian Foundation for Medical Research 1949-50 and Senior Pediatric Fellow 1950-51. § Preliminary reports of this study have been published.12 A more inclusive report of methodology and a report of a statistical analysis of the relationship of maternal attitudes in child care practices and the child's behavior in 50 mother-child couples is in process of preparation by Dr. E. H. Klatskin and the writer. opportunity to learn about the care of her infant, first by observation of the nurse, and then by practice under the nurse's supervision. A mother should not be expected to take care of her infant until she felt ready to do so. The father should be allowed to visit his wife and baby together and share the parental satisfaction of holding his infant and learning general aspects of infant care. Precautions similar to those of attending physicians should be carried out by visiting fathers before holding the baby. Daily visiting hours should be arranged. (Fortunately, it developed that they could be arranged twice daily.) Visitors should be limited to the father and two close relatives or friends for the duration of the rooming-in stay, and only one of these visitors should be allowed at a time. The rooming-in unit was opened and maintained with few exceptions on the foregoing principles and there were usually more than enough applicants to fill it. It proved an immediate success, judging by the appreciative response of participating parents, nurses,2"7 and doctors.' The mothers' appreciation was noted in their attitude and conversation in the unit, their enthusiastic remarks to the unit's professional visitors, their favorable reports on comment cards returned to the hospital director's office, in their "impressions" written for the rooming-in staff, in their zeal for writing up their experience,"'6 and for participation in panel discussions, and finally in their eagerness to return with subsequent babies. With the successful realization of plans there developed a group feeling of parenthood for the unit and a sense of pride in its performance. Dr. Thoms, whose enthusiastic sponsorship for rooming-in on his* maternity service has been noted above, felt that rooming-in really belonged to obstetrics, and should be promoted by obstetricians principally through obstetric channels.' Miss Hyder, with her tremendous zeal for "revitalizing" the teaching and practice in obstetrical nursing, regarded the roomingin unit as a direct means to this end and staffed the unit as far as possible with student nurses.8 Dr. Powers and the writer, through their close association during the preliminary planning years, saw the unit as a means of introducing pediatricians-in-training to an important aspect of their future work, but primarily as a measure for wholesome family integration and avoidance of anxieties and misunderstandings that arise when family members are kept apart."' Dr. Snoke and Dr. Foord regarded it as an indicator for future architectural and administrative plans.24'5 The early favorable responses indicated probable continued success for the "experiment" and encouragement for eventual expansion. Very soon after this heartening start, developments in the Department of Obstetrics began which added greatly to the effectiveness of the rooming-in program. Three mothers who had expressed a wish to have rooming-in * In 1947, Dr. Thoms was appointed professor of obstetrics and gynecology, and obstetrician- and gynecologist-in-chief of the Grace-New Haven Community Hospital University Service. independently approached their obstetricians with a request to have natural childbirth also. They had read either Grantly Dick Read's book! or the popular account' of his theory and the application of it in this country by Dr. Blackwell Sawyer. They won sympathetic interest from their respective physicians, Dr. Thoms, Dr. Frederick W. Goodrich, Jr.,* and Dr. Margaret Tyler.t All three babies were successfully delivered by the "Read" method in January 1947, at the very time when Dr. Dick Read was in this country at the invitation of the Maternity Center Association of New York. When he came to New Haven for a lecture to Dr. Thoms' staff and students, he was taken to see the rooming-in unit. It was a pleasant coincidence that one of the three mothers who had followed suggestions from his book, Mrs. Olmsted, wife of the rooming-in fellow, was there to greet him and report her success with his method. Thus, again, the desire of mothers for a more natural approach to hospital maternity care, coupled with a sympathetic professional response, started modifications in obstetric procedure. These changes, together with the rooming-in plan, grew into an integrated program of maternity education as defined in the introductory quotation. Dr. Thoms, with the able assistance of Dr. Goodrich' and Miss Hyder, initiated the program. This became well established during 1948. Dr. Thoms assembled the details of the program in book form in a remarkably clear and graphic way under the title, Training for Childbirth: A Program of Natural Childbirth wuith Rooming-in.' It was immediately obvious that the two programs were "part and parcel' of each other, that they shared a basic philosophy of parental education, with emphasis on parents' participation in procedures and in knowledge about processes which affect them and their infants. The integration of the two programs brought the answer to Dr. Powers' plea for co-operation and understanding between obstetricians and pediatricians for "a unified program as to management and maternal nursing." Dr. Wessel worked in close liaison between the resident obstetric and pediatric staffs and was active in the teaching program for nurses and for parents in both the training for childbirth and the rooming-in programs. The growing popular and professional support of the integrated programs put pressure on the administration to expand rooming-in facilities. The addition of another unit in October 1948t made it possible to accommodate the majority of mothers registered in prenatal clinic who wanted rooming* Assistant resident in obstetrics and gynecology. t In private practice, and associate clinical professor of obstetrics and gynecology. 4 This was first set up as a five-bed unit in the interests of "A Time Study of Nursing Activity in Rooming-in." This study was under the sponsorship of the Department of Health of the State of Connecticut, assisted by the Children's Bureau of the Federal Security Agency. It was carried out under the direction of Barbara Lucas Holman, R.N., graduate student in the Department of Public Health. The report has not been published, but copies are available for reference. When the Time Study was completed, the five-bed unit was reduced to four beds. A93 in. There was also pressure from some families who had private obstetricians, especially those affiliated with the medical school and hospital. In the absence of rooming-in accommodations in the private pavilion, a monthly quota of six private patients for the rooming-in unit was approved by Dr. Thoms and Dr. Snoke. The private patients who wanted rooming-in were so eager to assure themselves a reservation that they applied very early-a few as soon as they thought they were pregnant but before the diagnosis had been confirmed by their obstetricians! The quota for any given month was usually filled six months ahead. For the numerous private patients who had to be disappointed, the promise of a new hospital building with facilities to accommodate all mothers who wanted rooming-in was definitely made. The units were maintained in continuous operation for six and four years respectively, closing only for occasional days during low census periods or for redecoration. The combined response of parents and staff continued to be consistently favorable. Rooming-in facilities in several hospitals elsewhere were modeled after the New Haven Hospital units, and similar observations were reported.' That the units continued to be spoken of as "experimental" was due to the original association with the Research Project. As the Research Project moved into its final phase, the rooming-in units gradually became independent of it. The nursing fellowships ceased in June 1950,* and the pediatric fellowships in June 1951. For the following academic year (1951-52), a grant to the Department of Pediatricst permitted the appointment of two clinical fellows to continue the service aspects of the rooming-in program. These could not be carried on adequately by the existing resident staff without additional help. For the year 1952-53, Dr. Milton J. E. Sennt recommended the appointment of two additional pediatric assistant residents to conduct the neonatal and well baby services in the hospital. With this change, the rooming-in set-up came into its own as a hospital service. It continued to provide the same general satisfactions as it had in its more protected days. It had hardly become used to its independence when the transfer on February 23, 1953 of all maternity patients from Dr. Thoms' service and the private pavilion to the new Memorial Unit of the Grace-New Haven Community Hospital introduced rooming-in at Yale to its major test of maturity. *The four nursing fellows were Mrs. Carolyn Krementz, Miss Nilda Shea, Miss Madeline McKenna, and Miss Gail Graham. t From the Children's Bureau of the Federal Security Agency. t Dr. Senn, Sterling Professor of Pediatrics and Psychiatry, on the retirement of Dr. Powers succeeded him as pediatrician-in-chief of the Grace-New Haven Community Hospital University Service. The Yale Journal of Biology and Medicine PubMed Central

The Development of Rooming-in at Yale *

The Yale Journal of Biology and Medicine , Volume 25 (6) – Jun 1, 1953
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