A Call to Action and a Challenge to Use a Standard to Measure Mother-Friendly Birth Classes

Abstract

In spite of the efforts of numerous organizations and individuals to offer mother-friendly birth information and care in the United States, the nation remains a highly technical, low-touch birth culture with a decline in positive maternal-fetal outcomes. A number of organizations and individuals came together to form the Coalition for Improving Maternity Services and to create the Mother-Friendly Childbirth Initiative (MFCI). The MFCI is a wellness model of maternity care that offers 10 evidence-based steps of care that will improve birth outcomes and reduce costs. Birth educators can use this self-assessment tool to provide the same evidence-based information.

A growing concern exists in the United States over the kind of birth care provided for mothers, babies, and families. Childbirth educators are perplexed with the numbers of mothers taking Lamaze classes who do not even consider any options other than “my epidural.” Health care professionals cannot discern why the cesarean rate is not decreasing—in some areas, the rate is on the rise (Ventura, Martin, Curtin, Menacker, & Hamilton, 2001).

As educators, we have long known about the value of the consumer in affecting change. In theory, we educate the consumer, the consumer negotiates and gets the desired choices, old habits are changed, and more consumers get more choices. We started out teaching with the belief that, in a few years, birth would be considered normal and natural. But today, we see no evidence that choices are any more available than they were in the early 1970s. Only the interventions have changed and increased.

Well, you say, we childbirth educators are not the problem. It's the generation that trusts buttons and machines and chemicals more than their own bodies. It's the doctors who jump-start the labor process before the mother's body and the baby are ready. It's the nurses who have lost the knowledge of high-touch care in their high-tech facilities. The Coalition for Improving Maternity Services (CIMS) and its centerpiece document, the “Mother-Friendly Childbirth Initiative” (MFCI), were born out of these same frustrations (see Appendix).

If we want to witness change, birth educators can no longer straddle the fence, avoid the word pain, or present routinely used medical interventions as if they were completely safe and risk-free. To do otherwise is to contribute to the damage to our culture that is insidious and visible. Choice must be based on knowledge of consequences. Without guidance, families are coming to believe that they no longer have to participate in making any decisions in the areas of pregnancy, labor, or birth. Conception can be achieved in a test tube, another woman can give birth to a mother's baby, and someone else can feed and raise the children. It follows that, as a society, we become less bonded to our children. In a culture that does not value its children, we all lose. What does this mean for childbirth educators? What things can childbirth educators do to become more mother-friendly? Who supports you in that endeavor?

Become Aware of the Problem

Upon hearing about water births and birth balls, parents in our Lamaze classes cannot understand why their friends have not heard about choices or the philosophy of birth that Lamaze International crafted in 1995. This philosophy of birth begins with the statement, “Birth is normal, natural, and healthy,” and ends with, “Childbirth education empowers women to make informed choices in health care, to assume responsibility for their health and to trust their inner wisdom” (see Table 1). Yet, we seem to be spinning our wheels, and the knowledge of normal birth remains some hidden secret that the women in our culture have not shared with one another, even after years of our advocacy. The following is a discussion of some actions the childbirth educator can take to strengthen our advocacy role.

Table 1.

Lamaze Philosophy of Birth^*

• Birth is normal, natural, and healthy.

• The experience of birth profoundly affects women and their families.

• Women's inner wisdom guides them through birth.

• Women's confidence and ability to give birth is either enhanced or diminished by the care provider and place of birth.

• Women have a right to give birth free from routine medical interventions.

• Birth can safely take place in birth centers and homes.

• Childbirth education empowers women to make informed choices in health care, to assume responsibility for their health and to trust their inner wisdom.

^*Lamaze International, Inc. (2000). Lamaze philosophy of birth. Lamaze International, Inc. [On-line]. Available: http://www.lamaze.org/2000/about_lamaze.html. Copies are also available from Lamaze International's offices: write 2025 M Street NW, Suite 800, Washington, D.C. 20036–3309; or call (800) 368–4404 or (202) 367–1128; or fax (202) 367–2128.

Keep Current in Your Knowledge Base

You can become more knowledgeable about the research concerning birth practices. Such information has been collected and evaluated for over 30 years by the Cochrane Collaboration. The Cochrane Database is available in a variety of formats. You can purchase the complete database in book form or on CD, or you can access database information via the Internet (www.cochrane.org). Another excellent resource for educators is the book, A Guide to Effective Care in Pregnancy and Childbirth (Enkin, Keirse, Renfrew, & Neilson, 2000). This book evaluates the available medical evidence supporting a vast number of obstetrical practices. It is indispensable reading for the educator who hopes to assist her students in making informed decisions about their care. A Guide to Effective Care in Pregnancy and Childbirth is available at the Lamaze International bookstore (www.lamaze.org). Another invaluable resource is Childbirth Education: Practice, Theory and Research (Nichols & Humenick, 2000), a textbook that was written largely by Lamaze faculty. This book won an American Journal of Nursing Books of the Year Award in part because its coverage of childbirth education is evidence-based.

Stay Connected

Attend the Lamaze International annual conference (scheduled this year for October 4–7, 2001, in Minneapolis, MN) and you'll be revitalized and updated to ensure your teaching is mother-friendly. Lamaze also offers one-day workshops, presented by the Lamaze faculty, on updating your information and teaching methods with research. Sponsor a workshop for you and other educators in your area.

Know your rights as a provider of birth education. Do you want to be an independent contractor or an employee of the agency for which you teach? Be in a position to make informed choices about the information you provide to your clients. Make sure your teaching aids reflect current research and allow for cultural variations. Attending workshops, specialist trainings, and conferences provided by Lamaze will expose you to numerous teaching resources.

Be in a position to make informed choices about the information you provide to your clients.

Link for Power to Advocate

In 1994, Lamaze International pulled together women and men as leaders in their respective birth-related organizations to explore working together, rather than competing, to change the culture of birth. From this start, CIMS was formed. As a coalition of organizations, their mission became “to promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs. This evidence-based mother-, baby-, and family-friendly model focuses on prevention and wellness as the alternatives to high-cost screening, diagnosis, and treatment programs” (CIMS, 1996, p. 1). The group worked towards producing a document that defines mother-friendly services that are guided by the following principles:

• Promote birth as a normal, natural, and healthy process.

• Empower a woman to develop confidence in her ability to give birth and care for her baby.

• Give a woman autonomy to make informed choices about the care she and her baby receive.

• Do no harm by applying only medically necessary interventions.

• Take responsibility for the quality of care provided, which should be based on the needs of the mother and child. (CIMS, 1996)

This document outlines 10 important steps for hospitals, birth centers, and home-birth services to take in order to become mother-friendly. The document can be obtained from the CIMS national office.1

You can also become involved with CIMS. Contact their national office and find out information about their next yearly meeting (usually held in February). Log on to their web site and download their “Mother-Friendly Childbirth Initiative” (MFCI) document. Include in your class handouts the consumer version of the MFCI document, “Having A Baby? Ten Questions to Ask,” which is also available on the CIMS web site. Finally, you can help support the MFCI by obtaining a copy of the endorsement form (available from CIMS and located on their web site) and signing and returning the form to the CIMS national office.

Birth Networks

One of the unexpected outcomes from the resurgence of normalcy in birth via CIMS has been the emergence of grassroots consumer groups based on the MFCI. Several of these have adopted the name of birth networks. Find out if there is a birth network near you or help parents to organize one.2 This movement towards mother-friendly birth will grow and flourish. Never before in our history have the birth organizations and professionals united in such an effort. You, too, can become a part of this surge forward.

One of the unexpected outcomes from the resurgence of normalcy in birth via [the Coalition for Improving Maternity Services] has been the emergence of grassroots consumer groups based on the [Mother-Friendly Childbirth Initiative].

Evaluate Your Classes or the Birth Services Available in Your Community

What about the education you provide in your birth classes? This is where the childbirth educator can make a difference. Thus, this author challenges you to evaluate your classes. To measure your own mother-friendly approach, ask yourself the questions outlined in Table 2.

Table 2.

Questions to Ask in Order to Measure One's Mother-Friendly Teaching Approach in Childbirth Education Classes^*

(continued on next page)

Table 2 (continued from previous page)

© 2001 by the Coalition for Improving Maternity Services. Permission to reprint this table may be obtained by contacting the CIMS national office. Write to CIMS at P.O. Box 2346, Ponte Vedra Beach, FL 32004 or call (888) 282-CIMS or (904) 285-1613.

^*This list of questions is based on the document, “Having a Baby? Ten Questions to Ask,” which is available from CIMS. To obtain a copy of “Having a Baby? Ten Questions to Ask” contact CIMS or download the document from the web site link (http://www.motherfriendly.org/Ten_Questions/tenquestions.html).

You can observe that the Lamaze Philosophy of Birth and the MFCI propose the same ground rules for mother-friendly care. It is because they are both evidence-based and comprise the work of those committed to the whole experience of maternity care. That means they do not rely on the latest piece of sensational research upon which to base their guidelines. Rather, they rely on a collection of research conducted over a period of years—research that demonstrates effective, ineffective, harmful, and helpful practices in childbirth. As educators, the information we provide our clients must be evidence-based. It is our job to empower women to make truly informed decisions about their care and the care of their babies. The MFCI is designed for implementation by hospitals, birth centers, and home birth services. Lamaze education must be congruent with both the Lamaze Philosophy of Birth and the MFCI if we are to prepare and support women and their families for a satisfying and safe birth that is normal and natural.

It is our job to empower women to make truly informed decisions about their care and the care of their babies.

Report: Well-being of U.S. Children Improved Over Past Decade

According to a report recently released by the Annie E. Casey Foundation, the well-being of children in the United States improved over the past decade on 7 of 10 key measures. Improvements (declines) were noted in the following: infant mortality rate; child death rate; rate of teen deaths by accident, homicide, and suicide among 15- to 19-year-olds; teen birth rate among 15- to 17-year olds; percentage of teens ages 16 to 19 who are high school dropouts; percentage of teens ages 16 to 19 who are not attending school and not working; and percentage of children living with parents who do not have full-time, year-round employment.

However, the percentage of low-birthweight babies and the percentage of families with children headed by a single parent increased. Also, despite the decrease in the percentage of children in poverty since 1993, more than 16 million children have parents who struggle to make ends meet, even though they are employed all year.

Annie E. Casey Foundation (2001). Promising progress yet troubling trends face kids in the new millennium. Press release available at www.caseyfoundation.org/kidscount/kc2001/kc2001press.htm.

KIDS COUNT Data Book (2001). Washington, DC: Annie E. Casey Foundation. Report available at www.caseyfoundation.org.

The above news brief appeared in the May 25, 2001, electronic issue of MCH Alert (www.ncemch.org/alert/alert052501.htm). MCH Alert is produced by the National Center for Education in Maternal and Child Health in Arlington, VA (www.ncemch.org/alert).

Appendix

Brief History of the Coalition for Improving Maternity Services (CIMS)

At the Lamaze International conference in 1994, under the leadership of President Deborah Woolley, a summit was held to develop an action plan. Six invited heads of organizations met during the conference. These six people were Rahima Baldwin Dancy (Informed Homebirth/Informed Birth and Parenting), Carol Kolar (La Leche League International), Cathy Daub (Birthworks, Inc.), Sandra DeStaffany (International Childbirth Education Association), Jay Hathaway (the Bradley Method) and Judy Lothian (Lamaze International). Later, along with others, this group decided to meet again in July 1995 at the La Leche League International conference to work on a consensus statement on normal birth. About 25 people got together that July for half a day to begin drafting a standard for normal birth. The group also signed a supportive statement for the Baby-Friendly Hospital Initiative to be presented at the International Lactation Consultants Association conference later that month.

Through word-of-mouth information, other people heard about this effort and joined in on the meetings. To Roberta Scaer of Lamaze International, the whole process was like being on a train under a beautiful, black, starry night with the train racing along and stopping for others to get on board. “We weren't quite sure where we were going, but the ride was exhilarating.”

Two more meetings were planned for the fall of 1995, one on each coast in conjunction with conferences—the Association for Prenatal and Perinatal Psychology and Health conference in California and the BIRTH conference held a few weeks later in Baltimore, Maryland. Consensus was used for wording the developing standard. A wise decision was made not to make any changes in what had already been agreed upon at previous meetings; rather, changes were postponed.

It seemed a minor miracle that personal agendas were left at the door of each meeting, and participants came together to find what they could agree on about normal birth. Lamaze International served as the group's “midwife” throughout the process and kept it going by providing staff services (including Chris Murphy). The final meeting for the consensus standard document was held in the spring of 1996 at the Mount Madonna yoga retreat center in Santa Cruz, California, where Comet Hyakutake was visible in the night sky and redwood trees surrounded the area. Without chocolate, caffeine, or alcohol, coalition members had a verbal knockdown, drag-out, historic 2.5 days of continuous meetings in order to come to an agreement on the entire Coalition for Improving Maternity Services (CIMS) document. The group appointed a six-person editorial committee of writers to refine the document before it was sent out for ratification by two-thirds of the organizations and two-thirds of the individuals. The editorial committee worked for 6 weeks to polish the document for publication. Chris Murphy of Lamaze International sent the document out for ratification. In the rush of getting the document finalized at the Santa Cruz meeting, an organizational structure was left somewhat in the air. Roberta Scaer stepped in as volunteer coordinator and, with Chris Murphy, kept the ratification process on track. On July 1, 1996, Betsy Schwartz faxed in the vote that carried the ratification process to success (she was late with her vote because of the birth of her son, James). Along with Roberta Scaer and Chris Murphy, Jack Travis of Wellsprings, Inc. ushered the Mother-Friendly Childbirth Initiative into the printed form you see today (www.motherfriendly.org).

Many inspiring stories occurred during the ratification process. Mary Brucker (American College of Nurse-Midwives and Lamaze International) and Deb Woolley got the CIMS vote onto the board meeting agenda for the ACNM conference in May 1996. They ordered 800 copies of the CIMS document and distributed them to meeting participants who then demanded the board act upon it. Joy Grohar (then president of the Association of Women's Health, Obstetrical, and Neonatal Nurses) took the document to the board members of AWHONN and shepherded a complete and heated discussion. Finally, one woman spoke for all when she said, “We have to stand up for women on this!” The next 2 years of CIMS work were spent forming the coalition and establishing action goals.

It is extraordinarily exciting to be part of a process described by Peggy O'Mara, publisher of Mothering Magazine, in the following statement: “CIMS is the third wave of childbirth reform.” In her 1998 column, titled “A Call to Action,” featured in the May/June issue of Mothering Magazine, Peggy O'Mara describes the first wave of childbirth reform as the emergence of both the La Leche League and the International Childbirth Education Association in the 1950s. She identifies the second wave as the re-emergence of homebirth and midwifery in the 1960s and early 1970s.

Natural occurrences that have taken place during coalition meetings, so far, have been Comet Hyakutake, Comet Hale-Bopp, Florida tornadoes, and California earthquakes. It seems just a coincidence that some extraordinary meteoric or earth-moving event has accompanied each coalition meeting—but you won't convince those of us who were there that such phenomenas were “just coincidence.”