A retrospective cohort study was conducted at a BFHI-accredited medical center in southern Taiwan.

After approval to conduct the study was granted by the Institutional Review Board (No. A-ER-109–185), the electronic medical records (EMRs) of two groups of healthy postpartum women aged 18 years or older were analyzed. These women had no postpartum complications, contraindicating rooming-in or breastfeeding, and delivered healthy full-term neonates between January and December 2017 and between January and December 2019. As prenatal decision-making was influenced by infection control policies during the COVID-19 pandemic from 2020 to 2023, records were limited to 2019, prior to the onset of the pandemic. Sample sizes were not estimated prior to conducting the medical review to maximize the sample size and accommodate the cohort study design.

Data from the EMR were extracted for maternal and neonatal characteristics of interest. The data included (1) maternal demographic traits such as age, education level, marital status, and employment status; (2) maternal obstetric characteristics, including parity, number of fetuses, and mode of delivery; (3) neonatal characteristics, such as gestational age at birth (weeks) and birth weight (grams); (4) maternal knowledge, considerations, and prenatal intentions regarding postpartum rooming-in and breastfeeding during hospitalization; (5) actual postpartum rooming-in practices during hospitalization; and (6) actual breastfeeding practices from birth to hospital discharge, to 1 month, and to 2 months postpartum.

The EMRs included PDAs documenting women’s knowledge, considerations, and intentions regarding postpartum rooming-in and breastfeeding during hospitalization. The PDAs were developed by the Joint Commission of Taiwan using expert consensus [27]. The PDAs responses were only available for the 2019 cohort of postpartum women.

The PDAs for rooming-in include three subscales: knowledge, considerations, and intention. The knowledge subscale includes five questions, with each question rated as “yes” or “no.” Each correct response earns 1 point, resulting in a maximum score of 5. The considerations subscale comprises seven items, with endpoints ranging from 1 (least important/concerning) to 5 (most important/concerning). The single item for prenatal intention for rooming-in offers 3 options: 24-h rooming-in, partial rooming-in, and separate care [25, 27].

The PDAs for breastfeeding include three subscales: knowledge, considerations, and intention. The knowledge subscales include six questions, with each question rated as “yes” or “no.” Each correct response earns 1 point, resulting in a maximum score of 6. The considerations subscale comprises six items, with endpoints ranging from 1 (least important) to 5 (most important). The single item for prenatal intentions of breastfeeding offers three options: exclusive breastfeeding, mixed feeding, and formula feeding [27]. Exclusive breastfeeding was defined as infants who only received breast milk without any additional liquids or solids, including water. Mixed feeding was defined as being fed a combination of breast milk and other liquids. Formula feeding was defined as feeding with artificial formula.

During the postpartum hospital stay, each woman’s rooming-in and breastfeeding practices were documented based on their actual status. Rooming-in could be recorded as either 24-h rooming-in, partial rooming-in, or separate care, and breastfeeding could be recorded as exclusive breastfeeding, mixed feeding, or formula feeding. After discharge, breastfeeding practices from birth to 1 month and to 2 months postpartum were documented through structured follow-up phone calls. Before posing specific questions, nurses ensured that mothers understood the definitions of EBF, mixed feeding, and formula feeding, emphasizing that EBF involves feeding the baby only breast milk without any supplemental liquids or solids, including water. At one month postpartum, the question posed was “How has your baby been fed in the first month of life?” At two months postpartum, the question was, “How has your baby been fed in the first two months of life?” [28,29,30].

Continuous variables are presented as the means and standard deviations (SDs), while categorical variables are presented as percentages. For the analysis of continuous variables, the Wilcoxon rank sum test was applied to compare characteristics, postpartum rooming-in during hospitalization, and breastfeeding practices from birth to hospital discharge, to 1 month, and to 2 months postpartum for the 2017 and 2019 cohorts. The analysis of categorical variables involved the use of chi-square tests, and Fisher’s exact test was utilized when any expected cell size was less than 5. Kruskal–Wallis tests were conducted to examine factors influencing women’s prenatal rooming-in decisions. If the Kruskal–Wallis test indicated a significant difference, Dunn’s test was performed as a post hoc analysis, applying a Bonferroni correction with α set at 0.017. Non-parametric statistics were applied due to the non-normal distribution of the data.

All analyses were performed using SAS version 9.4 (SAS Institute) and R version 4.1.1 (R Foundation for Statistical Computing, Vienna, Austria), with the significance threshold set at α = 0.05.