THE MOTHER-FRIENDLY CHILDBIRTH INITIATIVE

[The First Consensus Initiative of the Coalition for Improving Maternity Services (CIMS)] Copyright 1996 by the Coalition for Improving Maternity Services (CIMS), POB 382724, Cambridge, MA 02238. Permission granted to freely reproduce in whole or in part with complete attribution.

MISSION

The Coalition for Improving Maternity Services (CIMS) is a coalition of individuals and national organizations with concern for the care and well-being of mothers, babies, and families. Our mission is 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.

PREAMBLE

Whereas: * In spite of spending far more money per capita on maternity and newborn care than any other country, the United States falls behind most industrialized countries in perinatal* morbidity* and mortality, and maternal mortality is four times greater for African-American women than for Euro-American women; * Midwives attend the vast majority of births in those industrialized countries with the best perinatal outcomes, yet in the United States, midwives are the principal attendants at only a small percentage of births; * Current maternity and newborn practices that contribute to high costs and inferior outcomes include the inappropriate application of technology and routine procedures that are not based on scientific evidence; * Increased dependence on technology has diminished confidence in women's innate ability to give birth without intervention; * The integrity of the mother-child relationship, which begins in pregnancy, is compromised by the obstetrical treatment of mother and baby as if they were separate units with conflicting needs; * Although breastfeeding has been scientifically shown to provide optimum health, nutritional, and developmental benefits to newborns and their mothers, only a fraction of U.S. mothers are fully breastfeeding their babies by the age of six weeks; * The current maternity care system in the United States does not provide equal access to health care resources for women from disadvantaged population groups, women without insurance, and women whose insurance dictates caregivers or place of birth; Therefore, We, the undersigned members of CIMS, hereby resolve to define and promote mother-friendly maternity services in accordance with the following principles:

PRINCIPLES

We believe the philosophical cornerstones of mother-friendly care to be as follows: Normalcy of the Birthing Process * Birth is a normal, natural, and healthy process. * Women and babies have the inherent wisdom necessary for birth. * Babies are aware, sensitive human beings at the time of birth, and should be acknowledged and treated as such. * Breastfeeding provides the optimum nourishment for newborns and infants. * Birth can safely take place in hospitals, birth centers, and homes. * The midwifery model of care, which supports and protects the normal birth process, is the most appropriate for the majority of women during pregnancy and birth. Empowerment * A woman's confidence and ability to give birth and to 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 interconnected-ness 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 for herself and her family, regardless of her age or circumstances; * Give birth as she wishes in an environment in which she feels nurtured and secure, and her emotional well-being, privacy, and personal preferences are respected; * Have access to the full range of options for pregnancy, birth, and nurturing her baby, and to accurate information on all available birthing sites, caregivers, and practices; * Receive accurate and up-to-date information about the benefits and risks of all procedures, drugs, and tests suggested for use during pregnancy, birth, and the postpartum period, with the rights to informed consent and informed refusal; * 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. Many standard medical tests, procedures, technologies, and drugs carry risks to both mother and baby, and should be avoided in the absence of specific scientific indications for their use. * If complications arise during pregnancy, birth, or the postpartum period, medical treatments should be evidence-based. Responsibility * Each caregiver is responsible for the quality of care she or he provides. * Maternity care practice 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 for mothers and babies. * 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. These principles give rise to the following steps which support, protect, and promote mother-friendly maternity services:

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TEN STEPS OF THE MOTHER-FRIENDLY CHILDBIRTH INITIATIVE FOR MOTHER-FRIENDLY HOSPITALS, BIRTH CENTERS,* AND HOME BIRTH SERVICES

To receive CIMS designation as "mother-friendly," a hospital, birth center, or home birth service must carry out the above philosophical principles by fulfilling the Ten Steps of Mother-Friendly Care: ________________________________________________________________

A mother-friendly hospital, birth center, or home birth service:

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; * 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 (flat on back with legs elevated) 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; * linking the mother and baby to appropriate community resources, including prenatal and post-discharge 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; * IVs (intravenous drip); * withholding nourishment; * early rupture of membranes*; * electronic fetal monitoring; other interventions are limited as follows: * Has an oxytocin* use rate of 10% or less for induction and augmentation*; * 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 (high-risk) hospitals; * Has a VBAC (vaginal birth after cesarean) rate of 60% or more with a goal of 75% or more.

7. Educates staff in non-drug 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 with congenital problems, to touch, hold, breastfeed, and care for their babies to the extent compatible with their conditions.

9. Discourages non-religious circumcision of the newborn.

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

1. Have a written breastfeeding policy communicated to all health care staff;

2. Train all health care staff in skills necessary to implement this policy;

3. Inform all pregnant women about the benefits and management of breastfeeding;

4. Help mothers initiate breastfeeding within a half-hour of birth;

5. Show mothers how to breast feed and how to maintain lactation even if they should be separated from their infants;

6. Give newborn infants no food or drink other than breast milk unless medically indicated;

7. Practice rooming in: allow mothers and infants to remain together 24 hours a day;

8. Encourage breastfeeding on demand;

9. Give no artificial teat or pacifiers (also called dummies or soothers) to breastfeeding infants;

10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from hospitals or clinics.

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* GLOSSARY

Augmentation: Speeding up labor.

Birth Center: Free-standing maternity center.

Doula: A woman who gives continuous physical, emotional and informational support during labor and birth. Doulas may also provide postpartum care services in the home

Episiotomy: Surgically cutting to widen the vaginal opening for birth.

Induction: Artificially starting labor.

Morbidity: Disease or injury.

Oxytocin: Synthetic form of oxytocin (a naturally occurring hormone) given intravenously to start or speed up labor.

Perinatal: Around the time of birth.

Rupture of Membranes: Breaking the "bag of waters."

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RATIFIED by these members of the Coalition for Improving Maternity Services (CIMS)

Organizations: Academy of Certified Birth Educators (Olathe, KS), Judie C. Wika, RNC, MSN, CNM, CCE, Linda M. Herrick, RNC, BSN, CCE, CD, Sally Riley, BSEd, CCE, CD, Co-Directors American Academy of Husband-Coached Childbirth (The Bradley Method(tm) ), (Sherman Oaks, CA), Jay & Marjie Hathaway, Executive Directors American College of Certified Nurse-Midwives (Washington, DC) American College of Domiciliary Midwives (Palo Alto, CA ), Faith Gibson, CPM, Executive Director American Society for Psychoprophylaxis in Obstetrics, Inc./Lamaze (Washington, DC), Deborah Woolley, CNM, PhD, FACCE, President Assoc. of Labor Assistants & Childbirth Educators (Cambridge, MA), Jessica L. Porter, Executive Director Assoc. for Pre-& Perinatal Psychology & Health (Geyserville, CA), David B. Chamberlain, PhD, President Assoc. of Women's Health, Obstetrics, and Neonatal Nursing (Washington, DC), Joy Grohar, RNC, MS, President Attachment Parenting International, (Nashville, TN), Lysa Parker, BS, Executive Director Birthworks, Inc. (Medford, NJ), Cathy E. W. Daub, RPT, CCE, President Doulas of North America (Seattle, WA), Barbara A. Hotelling, RN, BSN, CD, FACCE, President The Farm (Summertown, TN), Ina May Gaskin, President Global Maternal/Child Health Association (Wilsonville, OR), Barbara Harper, RN, President Informed Home Birth/Informed Birth & Parenting (Ann Arbor, MI), Rahima Baldwin Dancy, CPM, President Internatn'l Lactation Consultant Assoc. (Chicago, IL), Karen Kerkhoff Gromada, MSN, RN, IBCLC, President La Leche Leche League Internat'l, (Schaumburg, IL), Carol Kolar, RN, Director of Education & Outreach Midwifery Today (Eugene, OR), Jan Tritten, TM, Editor Midwives Alliance of North America (Newton, KS), Ina May Gaskin, President Midwives of Santa Cruz (Santa Cruz, CA), Roxanne Potter, CNM,Kate Bowland, CNM, Co-Directors National Assoc. of Childbearing Centers (Perkiomenville, PA), Susan Stapleton, MSN, CNM, President National Assoc. of Postpartum Care Services (Edmunds WA), Gerri Levrini, RN, MSN, CNAA, President North American Registry of Midwives (San Francisco, CA), Sharon Wells, Coordinator Wellness Associates, Inc. (Mill Valley, CA), John W. Travis, MD, MPH, Meryn G. Callander, ME, BSW, Co-Directors ___________________________________________________________ Individuals: Sondra Abdulla-Zaimah, MN, CNM, CPM, College Park, GA Shannon Anton, CPM, San Francisco, CA Susanne Arms, Bayfield, CO, _Immaculate Deception Brian Berman, Bainbridge Island, WA Mary Brucker, CNM, DNSc, Dallas, TX Raymond Castellino, DC, RPP. Santa Barbara, CA Robbie Davis-Floyd, PhD, Austin, TX, _Birth as an American Rite of Passage Tina Kimmel, MSW, MPH, Berkeley, CA Henci Goer, BA, ACCE, Sunnyvale, CA, _Obstetric Myths Versus Research Realities Dorothy Harrison, IBCLC, Edmunds WA Jack Heinowitz, PhD, San Diego, CA, _Pregnant Fathers Marshall Klaus, MD, Berkeley, CA, _Bonding-Building the Foundation for Secure Attachment and Independence Phyllis Klaus, CSW, MFCC, Berkeley, CA, _The Amazing Newborn Judith Lothian, RN, PhD, FACC, Brooklyn, NY Paulina G. Perez, RN, BSN, FACCE, Houston, TX, _Special Women James W. Prescott, PhD, Newport Beach, CA, _Brain Function and Malnutrition> Karen A. Salt, CCE, Highland Park, NJ Irene Sandvold, DrPH, CNM, Rockville, MD> Roberta M. Scaer, MSS, Boulder, CO, _A Good Birth, A Safe Birth Betsy K. Schwartz, MMHS, Coconut Creek, FL Penny Simpkin, PT, Seattle, WA, _The Birth Partner: Everything You Need to Know to Help a Woman through Childbirth Suzanne Suarez, JD, RN, Tallahassee, FL Sandy Szalay, ARNP, CCE, Seattle, WA Marsden Wagner, MD, MSPH, Copenhagen, Denmark, _Pursuing the Birth Machine Diony Young, Geneseo, NY _____________________________________________________________

A partial list of organizations and individuals endorsing this Initiative (growing constantly): Touch The Future, Long Beach, CA, Michael Mendizza, Editor The Compleat Mother, Minot, ND, Jody McLoughlin, Editor The Nurturing Parent Journal, Rapid City, SD, Jacqueline De Laveaga, Publisher Individuals Elisabeth Bing, RPT, FACCE, Co-Founder, ASPO/Lamaze, _Six Practical Lessons for an Easy Childbirth Larry Dossey, MD, _Prayer is Good Medicine Eunice K. M. Ernst, CNM, MPH, Perkiomenville, PA, Mary Breckinridge Chair of Midwifery Dorothy J. Jongeward, PhD, _Born to Win John H. Kennell, MD, Rainbow Babies & Children's Hospital, GAP Division, Cleveland, OH, _Mothering the Mother Jean Liedloff, _The Continuum Concept Ashley Montagu, PhD, _Touching Michel Odent, MD, _Birth Reborn Joseph Chilton Pearce, _The Magical Child

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BIBLIOGRAPHY

American College of Obstetricians and Gynecologists. Fetal heart rate patterns: monitoring, interpretation, and management. _Technical Bulletin_ No. 207, July 1995. ---. Guidelines for vaginal delivery after a previous cesarean birth. _ACOG Committee Opinion_ 1988; No 64. Canadian Paediatric Soc, Fetus, and Newborn Committee. Neonatal circumcision revisited. _Can Med Assoc J_ 1996;154(6):769-780. Enkin M, et al. _A Guide to Effective Care in Pregnancy and Childbirth._ 2nd rev ed. Oxford: Oxford University Press, 1995. (Data from this book come from the Cochrane Database of Perinatal Trials.) Goer H. _Obstetric Myths Versus Research Realities: A Guide to the Medical Literature._ Westport, CT: Bergin and Garvey, 1995. Bureau of Maternal and Child Health. Unity through diversity: a report on the Healthy Mothers Healthy Babies Coalition Communities of Color Leadership Roundtable. Healthy Mothers Healthy Babies, 1993. (A copy may obtained by calling (702) 821-8993 ext. 254. Dr. Marsden Wagner also provided maternal mortality statistics from official state health data.) International Lactation Consultant Association. Position paper on infant feeding. rev 1994. Chicago: ILCA, 1994. Klaus M, Kennell JH, and Klaus PH. _Mothering the Mother._ Menlo Park, CA: Addison-Wesley Publishing Company, 1993. ---. _Bonding: Building the Foundations of Secure Attachment and Independence._ Menlo Park, CA: Addison-Wesley Publishing Company, 1995. Wagner M. _Pursuing the Birth Machine: The Search for Appropriate Birth Technology_. Australia: ACE Graphics, 1994. (Dr. Wagner's book has the "General Recommendations" of _The WHO_ Fortaleza, Brazil, April, 1985 and the "Summary Report" of _The WHO Consensus Conference on Appropriate Technology Following Birth_ Trieste, October, 1986.

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HELP CIRCULATE THIS INITIATIVE

CIMS operates on volunteer labor and a minimal budget via donations. We ask your financial support (to CIMS at the address below), and even more important, your help in disseminating this Initiative as widely as possible. Publish it, give it away, e-mail it, send it to your newspaper editor, (include attribution), mention it on talk shows, etc. Get Electronic Copies of this Initiative Free For electronic copies of this Initiative, visit our website (http://www.motherfriendly.org) or send an e-mail message to "thedocument@listserv.mcn.org", typing the word "DOCUMENT" in the SUBJECT line (or those not yet online, please go to a friend who has e-mail). A text file will be returned automatically by e-mail that you can print or reproduce electronically in your publications (for embedded manual formatting instructions, substitute "FORMATTED" in the SUBJECT line). We urge you to e-mail multiple copies of this Initiative to everyone you know (it is helpful to append a personal note to it). Please request that they also forward it to as many people as possible. Get Paper Copies of this Initiative Inexpensively Write to: ALACE, POB 382724, Cambridge, MA 02238-2724, requesting that a copy be mailed to you (include SASE) or faxed (include fax number). You must include $3 US to defray costs ($4 Canada/Mexico, $5 all others). ___________________________________________________________

More Information For information about this Initiative-its history, ways to use it, what is envisioned for it, creative ways to support CIMS, etc., we have a list of Frequently Asked Questions (FAQs) which you can get by sending an e-mail message to "thedocument@listserv.mcn.org" with "FAQ" in the SUBJECT line. We welcome your comments and suggestions, with evidence-based material supporting your position. ____________________________________________________________

Join the Discussion: Join our online discussion group to contribute to the wider dissemination and utilization of the Initiative, especially if you are willing to serve as a liaison in getting a local hospital/birth center designated as mother-friendly. Send an e-mail message to cims@listserv.mcn.org typing the word "SUBSCRIBE" in the SUBJECT line.

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