Introduction

Abstract

The history of the Coalition for Improving Maternity Services as part of a global effort to promote normal birth is described. The principles underlying the Mother-Friendly Childbirth Initiative are presented, the Ten Steps of Mother-Friendly Care are identified, and the evidence basis for the Ten Steps is introduced.

HISTORY OF THE COALITION FOR IMPROVING MATERNITY SERVICES

In response to the expanding medicalization of birth and low breastfeeding rates, the 1990s saw a flurry of activity at both international and national levels to normalize birth and increase breastfeeding rates. In 1991, the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) launched the WHO Baby-Friendly Hospital Initiative and the Ten Steps to Baby-Friendly in an effort to ensure that all maternity services, whether freestanding or in a hospital, would become centers of breastfeeding support. In 1997, the WHO released Care in Normal Birth: A Practical Guide. A parallel process was at work in the United States. In 1994, Lamaze International invited sister organizations and stakeholders in the birth and breastfeeding communities to a birth summit in Chicago, Illinois. The goal of that summit was to foster collaboration in a national effort to promote, protect, and support normal birth and breastfeeding. The commitment of that group to work together resulted in the establishment of the Coalition for Improving Maternity Services (CIMS) and, 2 years later, the launch of the Mother-Friendly Childbirth Initiative and the Ten Steps of the Mother-Friendly Childbirth Initiative for Mother-Friendly Hospitals, Birth Centers, and Home Birth Services (Ten Steps of Mother-Friendly Care) (CIMS, 1996). Like the Baby-Friendly Hospital Initiative, the Mother-Friendly Childbirth Initiative is intended to help hospitals as well as birthing centers and home birth services provide care that is “mother-friendly.”

The Mother-Friendly Childbirth Initiative was the first consensus declaration to deal with labor and birth by a multidisciplinary body of professional organizations and individuals in the history of North America. Members of CIMS that developed and ratified the Mother-Friendly Childbirth Initiative included childbirth educators, maternity care nurses, midwives, physicians, doulas, lactation consultants, grassroots advocates for normal birth and breastfeeding, maternity care researchers, university professors, experts in maternal mental health, authors, and parents. The participants met at forums across the United States from 1994 to 1996 to identify the philosophical cornerstones of the Mother-Friendly Childbirth Initiative and, then, to define what practices constituted mother-friendly care. At the time of the signing of the Mother-Friendly Childbirth Initiative, there was representation from 26 organizations (acting on behalf of over 90,000 childbirth professionals and advocates) and 28 individuals (CIMS, 1996).

PHILOSOPHICAL CORNERSTONES OF THE MOTHER-FRIENDLY CHILDBIRTH INITIATIVE

Normalcy of the Birthing Process

Birth is a normal, natural, healthy process, and women and babies have the inherent wisdom necessary for birth. Babies are aware, sensitive human beings at birth. Breastfeeding provides optimum nourishment for newborns and infants. Birth can safely take place in hospitals, birth centers, and homes. The midwifery model of care, supporting and protecting the normal process of birth, is the most appropriate care for most women during pregnancy and birth.

Empowerment

A woman's confidence and ability to give birth and care for her baby are enhanced or diminished by every person who gives her care and by the environment in which she gives birth. A mother and baby are distinct, yet interdependent, during pregnancy, birth, and infancy. Their interconnectedness is vital and must be respected. Pregnancy, birth, and the postpartum period are milestone events in the continuum of life. These experiences profoundly affect women, babies, fathers, and families and have important and long-lasting effects on society.

Autonomy

Every woman should have the opportunity to have a healthy and joyous birth experience and to give birth as she wishes in an environment in which she feels nurtured and secure and in which her emotional well-being, privacy, and personal preferences are respected. She should have access to the full range of options for pregnancy, birth, and nurturing her baby; receive accurate and up-to-date information about the benefits and risks of all procedures, drugs, and tests; and be allowed the rights of informed consent and informed refusal. Finally, she should receive support for making informed choices about what is best for her and her baby based on her individual values and beliefs.

Do No Harm

Interventions should not be applied routinely during pregnancy, birth, or the postpartum period. If complications arise, medical treatments should be based on the latest high-quality evidence.

Responsibility

Each caregiver is responsible for the quality of care she or he provides. Maternity care practices should be based not on the needs of the caregiver or provider, but solely on the needs of the mother and child. Each hospital and birth center is responsible for the periodic review and evaluation, according to current scientific evidence, of the effectiveness, risks, and rates of use of its medical procedures. Society, through both its government and the public health establishment, is responsible for ensuring access to maternity services for all women and for monitoring the quality of those services. Individuals are ultimately responsible for making informed choices about the health-care they and their babies receive.

TEN STEPS OF MOTHER-FRIENDLY CARE

These principles gave rise to the Ten Steps of Mother-Friendly Care, which support, protect, and promote mother-friendly maternity services. A mother-friendly hospital, birth center, or home birth service must fulfill the following steps:

1. Offers all birthing mothers:

   • unrestricted access to the birth companions of her choice, including fathers, partners, children, family members, and friends;
   • unrestricted access to continuous emotional and physical support from a skilled woman—for example, a doula or labor-support professional; and
   • access to professional midwifery care.

2. Provides accurate, descriptive, and statistical information to the public about its practices and procedures for birth care, including measures of interventions and outcomes.

3. Provides culturally competent care—that is, care that is sensitive and responsive to the specific beliefs, values, and customs of the mother's ethnicity and religion.

4. Provides the birthing woman with the freedom to walk, move about, and assume the positions of her choice during labor and birth (unless restriction is specifically required to correct a complication) and discourages the use of the lithotomy position.

5. Has clearly defined policies and procedures for:

   • collaborating and consulting throughout the perinatal period with other maternity services, including communicating with the original caregiver when transfer from one birth site to another is necessary; and
   • linking the mother and baby to appropriate community resources, including prenatal and postdischarge follow-up and breastfeeding support.
6. Does not routinely employ practices and procedures that are unsupported by scientific evidence, including but not limited to the following:

   • shaving,
   • enemas,
   • intravenous drips,
   • withholding nourishment,
   • early rupture of membranes, and
   • electronic fetal monitoring.

   Other interventions are limited, as follows:

   • has an induction rate of 10% or less;
   • has an episiotomy rate of 20% or less, with a goal of 5% or less;
   • has a total cesarean rate of 10% or less in community hospitals and 15% or less in tertiary care hospitals; and
   • has a vaginal birth after cesarean rate of 60% or more, with a goal of 75% or more.

7. Educates staff in nondrug methods of pain relief and does not promote the use of analgesic or anesthetic drugs not specifically required to correct a complication.

8. Encourages all mothers and families, including those with sick or premature newborns or infants who have congenital problems, to touch, hold, breastfeed, and care for their babies to the extent compatible with their conditions.

9. Discourages nonreligious circumcision of the newborn.

10. Strives to achieve the WHO/UNICEF Ten Steps of the Baby-Friendly Hospital Initiative to promote successful breastfeeding.

ONGOING RECOGNITION AND EVIDENCE BASIS FOR THE TEN STEPS

The Mother-Friendly Childbirth Initiative has received national and international recognition. An international survey in 2005 provided global support for the Ten Steps of Mother-Friendly Care (Pascali-Bonaro, 2006). In 2006, authorities of the WHO/UNICEF Baby-Friendly Hospital Initiative added an optional component to the baby-friendly assessment tools, which examines mother-friendly care. Each country will determine whether it will integrate this module as it updates assessment criteria and tools to the new standards (WHO, 2003). For the first time, the World Alliance for Breastfeeding Action (2006) has included a section on birth practices based on the Mother-Friendly Childbirth Initiative. In 2006, the international committee of CIMS working with Childbirth Connection organized a meeting in Geneva. Participants represented 19 national and international organizations, including Lamaze International; DONA International; the International Confederation of Midwives; the International Council of Nurses; the International Lactation Consultant Association; the Academy of Breastfeeding Medicine; the International Pediatric Association; the Partnership for Maternal, Newborn and Child Health; UNICEF; Wellstart International; the World Alliance for Breastfeeding Action; and the World Health Organization. The result of this collaboration is an international document: the MotherBaby International Childbirth Initiative. This global initiative is expanding the reach of mother-friendly and is solidifying awareness of the impact of birth on breastfeeding (CIMS, in press).

In the 10 years since the development of the evidence-based Ten Steps of Mother-Friendly Care, birth has become increasingly “intervention intensive” (Declercq, Sakala, Corry, & Applebaum, 2006). The cesarean rate in the United States has risen dramatically and, in 2005, reached an all-time high of 30.2% of births (National Center for Health Statistics, 2006). At the same time, there has been a sharp decrease in the number of vaginal births after cesarean (Declercq et al., 2006). An increasing body of research provides support for the value of normal physiologic birth and the dangers inherent in interfering in that process (Buckley, in press; Enkin et al., 2000). There is a deepening appreciation for the value of evidence that examines best possible outcomes rather than just risk and adverse outcome (Murphy & Fullerton, 2001).

As the crisis in birth escalates, it is critically important to assemble and scrutinize the evidence basis for the Ten Steps of Mother-Friendly Care. In this supplementary issue, we present the culmination of our efforts: a systematic review of the evidence in support of each of the Ten Steps of Mother-Friendly Care. Members of the CIMS Expert Work Group describe the methodology used and, then, present the rationales for complying with each step and a systematic review of the evidence for each step. Because the Ten Steps of Mother-Friendly Care is intended to advance mother-friendly care in birth centers and home birth services as well as hospitals, we determined it was important to look carefully at the state of the science related to birth outside the hospital. These findings are presented in the Appendix (see pp. 81S–88S).

Dedication to Sharron Humenick

Roberta Scaer, MSS

Before her untimely death on September 9, 2006, Sharron Humenick devoted her adult life to normal birth and breastfeeding. As a professor of nursing, Lamaze childbirth educator, and editor of The Journal of Perinatal Education, Sharron took every opportunity to publicize the intricate, physiological dance between mother and fetus that is normal birth and to publicize how normal birth is most likely to occur when the care provider observes but does not intervene with drugs, anesthesia, or surgery. Sharron knew if the mother and baby were seen as inseparable from birth and the pair were respected and treated as a dyad, the dance of breastfeeding is most likely to continue after birth.

The Mother-Friendly Childbirth Initiative (MFCI) and the Ten Steps of Mother-Friendly Care that lay out the practical application of the philosophy and principles of the MFCI were conceived and created by the consensus method over a 2-year period by several hundred maternity-care professionals, authors, and individuals with experience and knowledge of normal birth and breastfeeding. When Sharron first read the MFCI with its Ten Steps, she knew this historic document could be the catalyst for health professionals to support and protect normal birth and breastfeeding as the standard of care. She also knew that documentation of the research literature supporting the Ten Steps was a critical need for its use as evidence-based care.

Every one of us who had the privilege of knowing and working with Sharron felt empowered and always encouraged to base our work on scientific methodology. She was fearless in publicizing normal birth and breastfeeding as the gold standard of care for all women. She was equally fearless in demanding that research literature reviews be used to support the credibility of that care.

In the last weeks of her life, Sharron wanted so much to be part of the team bringing this document to fruition. She expressed regret that she was leaving life with so much left to do for normal birth and breastfeeding. We dedicate this document, Evidence Basis for the Ten Steps of Mother-Friendly Care, to Sharron Humenick, both to honor her commitment to normal birth and breastfeeding in practice and in proof and to present her commitment as a model for the reader.