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The International MotherBaby Childbirth Initiative:
A Human Rights Approach to Optimal Maternity Care
What exactly are the rights of the birthing mother? Visit www.imbci.org to read the entire 10 Steps of the IMBCI and see if your careor the care your provider offersfollows the optimal motherbaby model.
That right should be obvious and a given everywhere, yet any global glance will tell the observer that millions of women, in both developed and underdeveloped countries, are not receiving appropriate maternity care. Recent anthropological ethnographies describe women in India, Mexico, Tanzania, Papua New Guinea, Croatia, Canada and elsewhere saying the same thing about the care they receive in biomedical clinics and hospitals: They expose you, they shave you, they cut you, they leave you alone and dont come when you call, and they wont allow your relatives to be with you. Here is a highly representative quote from anthropologist Pauline Kolenda, describing birth in a hospital near a small village in India:
Before entering the hospital we have first to decide how much money we have to give. We are not admitted unless we first give them money. When the woman enters into the hospital, the doctor behaves rudely with her. Sometimes nurses beat her. They do not let close and affectionate relatives, who came from home with us, stand at our side. They themselves do not stay near us. We wish that somebody [would] hold us by the waist when pains come, but they do not do it. We have not even to moan, lest they talk sarcastically, make fun of us, which is very [hurtful] still we have to bear. If we moan too much, they may sometimes slap us. If we happen to say something, they retort by asking us whether they had invited us to come. Why have you come then? You may go back home! In hospital, we have to lie down on the bed to get delivered. In the hospital they excise the vaginal wall with a blade for enlarging it. The body gets damaged unnecessarily. After delivery we feel terribly hungry, but we consider ourselves lucky if we get a cup of tea.(1)
Consider the following description of a hospital birth in rural Papua New Guinea from the doctoral dissertation of Julia Byford, an Australian nurse-midwife who also became an anthropologist:
Mispa, a young woman of 20, was admitted to the hospital this morning. She is seen by the Health Examination Officer, who does a vaginal exam and tells me that she is 45 cm dilated and that she may commence a Syntocinon infusion .The labour room is small . There is a sink but no plumbing to allow it to be operational. There is no water at the hospital today anyway . Mispa asks to sit on the floor and is given permission to do this, but as her labour progresses the nurse says she must stay on the bed so the staff can do their observations. Most of the time she is left alone. She has not eaten all day and only drunk a small amount of water. Her lips are dry and swollen. The staff do numerous vaginal examinations but none of them are recorded [so when a shift changes, another exam is performed] .
During the second stage of labour, every time Mispa has a contraction, the Health Examination Officer [HEO] inserts a few fingers into Mispas vagina between the perineum and the babys head in order to stretch the perineum. Mispa finds this excruciating and tightens her grip on my arm . [After the birth] I am dismayed although not surprised to see that the baby is flat and pale and requires resuscitation. The HEO delivers the placenta by placing one hand on Mispas abdomen and pulling on the umbilical cord with the other hand as soon as the placenta is out, Mispa has a large postpartum hemorrhage. The HEO asks me to increase the intravenous infusion rate and then inserts her hand high up into Mispas vagina and manually removes some retained placental pieces. This is done without explanation or anesthetic. … Perhaps the hardest thing for me to come to terms with is the lack of care offered to Mispa simply on a human level. She was never consulted, only told what to do and what not to do. … No one tended to her basic needs for food or fluids or inquired if she needed to go to the toilet. It was as if Mispa, the embodied person, did not exist.(2)
In other words, Mispas basic human right to humane health care was utterly violated; she and her baby survived in spite of, not because of, their biomedical care. That care was not based on consideration of the mothers needs or on scientific evidence, but rather on Western biomedical models of labor and birth managementa traditional, not evidence-based, system that defines the doctor as the expert, the midwives and nurses as his or her expert support team, and the mother as an inexpert patient reliant on authoritative others to generate the successful birth of the baby. This globally dominant model ensures that its practitioners will generally be trained only in the biomedical management of birth and untrained in how to support the normal physiological and psychological process of birth.
In her ethnography of birth in a Canadian hospital, Hélène Vadeboncoeur concluded, Whilst women are treated kindly and attention is paid to them in this hospital, there is very little respect for the birth process and the physiological nature of this event.(3) Her study is in line with many others demonstrating the extreme biomedical lack of understanding of how to properly facilitate normal birth in both the developed and developing worlds. The global biomedical lack of awareness about normal birth generates faulty, overly interventive care that violates womens basic human right to appropriate care during labor and birth.
What constitutes appropriate care? From our perspective as long-time students of the subject, we can say with some authority that appropriate maternity care should first and foremost address the psychology of the mothershe should always be treated by her caregivers with respect and compassion and with efforts to instill confidence in herself and in her ability to give birth. And secondly, appropriate maternity care should be soundly based on the scientific evidence about the normal physiology of pregnancy, labor, birth and breastfeeding, which means that whether or not midwives themselves are the primary practitioners for labor and birth, what is internationally known as the midwifery model of care should always be the basic underlying ideology of birth practice. We need to shift the global paradigm to birth practices that promote optimal birth, such as those put forth in the International MotherBaby Childbirth Initiative (www.imbci.org).
The International MotherBaby Childbirth Initiative (IMBCI): 10 Steps to Optimal Maternity Care was created and developed in 2008 by the International MotherBaby Childbirth Organization (IMBCO), a non-profit NGO that grew out of the US-based Coalition for Improving Maternity Services (CIMS) to focus on the international arena. The purpose of the IMBCI 10 Steps is to improve care throughout the childbearing continuum, in order to save lives, prevent illness and harm from the overuse of obstetric technologies, and promote health for mothers and babies around the world. The IMBCI is a testament to and an affirmation of womens fundamental rights during childbirth. Its educational purpose is to call global attention to: the importance of the quality of the mothers birth experience and its impact on the outcome; the risks to mother and baby from inappropriate medical interventions; and the scientific evidence showing the benefits of motherbaby-centered care based on the normal physiology of pregnancy, birth and breastfeeding and attention to womens individual needs. The instrumental purpose of the IMBCI 10 Steps is to put into worldwide awareness and practice the motherbaby (midwifery) model of carea woman-centered, non-interventive approach that promotes the health and wellbeing of all women and babies during pregnancy, birth and breastfeeding, setting the gold standard for excellence and superior outcomes in maternity care.
The IMBCI acknowledges that womens rights are human rights and that women have a right to informed decision-making and to receive care that is evidence-based for themselves and their babies. The IMBCI recognizes the effects of birth practices on maternal self-confidence and on breastfeeding, and the importance of cultural sensitivity and continuity of care. These core principles, along with the IMBCI 10 Steps, have the ability to transform birth and breastfeeding practices around the world. With infant and maternal mortality and morbidity at distressing rates, the IMBCI is a call to action that will help achieve the United Nations Millennium Development Goals (MDG) to improve the quality of care for mothers and babies of the world (www.un.org/millenniumgoals). The IMBCI provides the structure and framework for achieving not only the MDG goals but also for respecting and supporting womens human rights during the childbearing continuum.
In addition to assuring optimal care during labor and birth, the IMBCI recognizes motherbaby as one unit, a dyad, not to be separated. The World Alliance for Breastfeeding Action (WABA), which constitutes part of the IMBCI Technical Advisory Group, issued the following statement at the Second WABA Global Forum in Arusha, Tanzania, in September 2002:
Breastfeeding is a basic human right and it is agreed that the protection of womens right to breastfeed is a shared position of the womens movement and breastfeeding movement. Women can fully exercise this right only where there exists a gender-equal social and political environment, whereby womens contribution to productive and reproductive work, including nurturing, is recognized, and where all forms of breastfeeding support can be made available. Gender equity is therefore basic to the breastfeeding movement.
Step 1 of the IMBCI 10 Steps crystallizes the essence of these issues. It states that an optimal maternity care service should treat every woman with respect and dignity, fully informing and involving her in decision-making about care for herself and her baby in language that she understands, and providing her the right to informed consent and refusal. Recently, IMBCI Executive Administrator Rae Davies undertook a survey of IMBCI country representatives. Respondents included representatives from Argentina, Brazil, Peru, Belize, Haiti, Hungary, Holland, Switzerland, Slovenia, the Czech Republic, India, Israel, Bangladesh, New Zealand and Canada. These representatives vary in profession among midwives, obstetricians, pediatricians, doulas, childbirth educators, lactation consultants, researchers, sociologists, presidents of organizations, writers, lobbyists and founders of NGOs. They are all supporters of the IMBCI.
The survey asked them which of the IMBCI 10 Steps were most relevant and most important for their countries. The overall consensus was that Step 1 is the most important. In responding, the Bangladeshi representative stated, It is alarming to note that 14% of maternal death in Bangladesh is due to violence or injury inflicted on pregnant women. … Caring behavior is essentially needed to meet the crisis prevailing in the Bangladeshi community. The Czech representative, Eliska Kodysova, noted that in her country, Maternity care providers just dont seem to know how sensitive a birthing woman is and often try to shut her up if shes too loud (now more often by offering an epidural, I admit) or criticize her deficient performance. Hospitals are very focused on giving women a safe childbirth by providing all technology and interventions possible. Midwives are becoming medwives.
Our Brazilian representative, Daphne Rattner, pointed out that in her country, Most women are disrespected during childbirth in a shameful manner … they are treated as patients and asked to hurry up with [a] lot of screaming, so their experience is traumatic rather than pleasurable. This general country consensus on the importance of Step 1 clearly illustrates the importance of calling attention to birth as a human rights issue.
According to the survey respondents, the next most important of the IMBCI 10 Steps are Step 2: Possess and routinely apply midwifery knowledge and skills that enhance and optimize the normal physiology of pregnancy, labour, birth, breastfeeding and the postpartum period; Step 5: Provide evidence-based practices proven to be beneficial; and Step 6: Avoid potentially harmful procedures and practices.
The Brazilian representative noted that, As we dont have midwives, only obstetric nurses, the midwifery knowledge will have to be reconstructed in our country, while our New Zealand representative stated, I and others here hope that IMBCI Steps 5 and 6 [will] help re-educate the health bureaucrats, doctors and midwives of New Zealand to promote, protect and encourage physiological childbirth! … Step 2 is also significant in New Zealand for, sadly, there also needs to be a re-birth or ascendancy of midwifery knowledge and skills that enhance and optimize the normal physiology of pregnancy, labour, birth, breastfeeding and the postpartum period.
Most of us hold the New Zealand midwifery-based system in high esteem, making her comment that even New Zealand midwives must work to maintain adherence to the midwifery model of care all the more significant. The same sort of acknowledgement comes from a northern Europe representative, who stated,
Its at a different level in countries like Holland and Switzerland. In principle, all the Steps are followed, so its hard to say which one is lacking in implementation. If anything, it would be to maintain the midwifery model of care in the secondary and tertiary levels of care and to provide drug-free pain relief (epidurals are increasing), and finally, probably to support and promote breastfeeding. So Steps 2, 4 and 10. But they all have to do with the amount of time staff have to invest, rather than with the actual knowledge and implementation of these Steps. All facilities have to be efficient and make the best possible use of resources (human and other), so a lot of the one-on-one care is gone .
It is for such reasons as these that the IMBCI 10 Steps were carefully designed during two years of work with experts around the world to be equally applicable to countries and birth facilities in both the developed and the developing world. The hegemony of the biomedical model is strong in most countries, thus every effort to replace that model with a midwifery ideology and motherbaby-centered practice must be made.
It is a well-known fact that more than 500,000 women die around the world due to maternity-related issues each year. The immediate, emergent causes of maternal death during birth include hemorrhage, eclampsia, sepsis and obstructed labor. Thus, Step 8 of the IMBCI calls for emergency obstetric care to be available and accessible. Yet the IMBCI acknowledges that this is not the sole solution to reducing maternal and neonatal morbidity and mortality. The deeper underlying causes of such conditions include poverty, malnutrition, overwork, underpay and the general cultural devaluation of womenespecially in developing countries with high maternal mortality rates. Step 7 notes that these problems must also be addressed at their sources through measures designed to prevent illness and promote wellness, and to empower women.
Mortality is not the only issue here. Morbidityunnecessary injury to mother and childis also a serious concern. A major strength of the IMBCI is its focus on avoiding practices that have been scientifically shown to do harm. For example: Hospital policies that restrict the mothers ability to eat or drink at- will can lead to weakness from hunger that complicates labor and birth; over-performance of vaginal exams can lead to infection; Pitocin induction can lead to dysfunctional labor and premature birth; Pitocin augmentation shuts down a mothers own oxytocin production and interferes with her ability to breastfeed; and epidurals can increase the length of the first and second stages of labor and lead to increased use of forceps and vacuum extraction, and possibly cesarean section.(4)
The World Health Organizations (WHO) 1985 statement that There is no justification for any region to have caesarean section rates higher than 1015%, has been largely ignored, as evidenced by the increase in c-section rates around the globe. (Editors note: In 2009, the WHO updated its stance on cesarean rates, stating that there is no optimum range and recommending that world regions may want to use a range of 515%, or set their own standards.)
In 2007, a group of WHO researchers and affiliates studied the underuse of cesareans in low-resource countries and overuse in high-resource countries (5), correlating cesarean rates with maternal, infant and neonatal mortality. Below 15%, higher c-section rates were unambiguously correlated with lower maternal mortality. Above this range, however, higher c-section rates were predominantly correlated with higher maternal mortality. A similar pattern was found for infant and neonatal mortality.(6) The often-ignored, negative, long-term consequences of cesareans include infection; chronic pain; difficulty with bonding and breastfeeding; maternal and neonatal injury and death; newborn respiratory problems; problems during future pregnancies, including higher risk of uterine rupture, ectopic pregnancy, preterm delivery, placenta previa, placenta accreta, and placental abruption that may necessitate hysterectomies; and increased incidence of postnatal depression.
The cesarean epidemic is transforming the nature of childbirth worldwide. The overuse of this operation that was designed to save lives is now costing them. Such evidence makes it crystal clear that the overuse of c-sections and other routine obstetric interventions constitutes a major violation of womens rights to appropriate care.
As the WABA statement quoted above mentioned, breastfeeding is also a basic human right. The IMBCI fully acknowledges that obstetrical practices can negatively impact a womans ability to breastfeed. Birth and breastfeeding cannot be separatedthey are part of the motherbaby continuumand the way birth proceeds can have a major impact on the way breastfeeding will proceed. Any procedure that interrupts the mothers physiological systems or interferes with her self-esteem can be highly detrimental to breastfeeding, including separation of motherbaby after birth and the use of bottles or pacifiers in the hospital. For these reasons, Step 10 of the IMBCI includes all 10 steps of the WHO/UNICEF Baby-Friendly Hospital Initiative (BFHI). Interference with the breastfeeding process can endanger babies health and chances of survival. For example, in developing countries where nutrition is poor, the water is not clean, and rates of infectious diseases are high, babies die at a significantly higher rate when they are not breastfed. Babies whose mothers are willing and able to breastfeed have a right to be breastfed for their health and survival, mothers have the right to be fully enabled to breastfeed, and health care practitioners must work to facilitate breastfeeding practices.
With the strength and power of the above statements and the political will to change, the International MotherBaby Childbirth Initiative (IMBCI) offers an evidence-based approach with 10 steps to achieve optimal motherbaby maternity care and consequently has launched a demonstration project that will put this model to work. Two hospitalsBrome-Missisquoi-Perkins Hospital in Cowansville, Quebec, Canada, and Hospital Regional de Tacuarembo in Tacuarembo, Uruguayare paving the way for demonstrating how maternity care services can comply with the human rights agenda and offer women optimal motherbaby maternity care. They are beginning the process of implementing the IMBCI 10 Steps in their respective institutions and will be carefully documenting and evaluating the effects. In addition to these two sites, IMBCO is making plans to include four additional demonstration sites in other areas of the world.
The full text of the IMBCI is available at www.imbci.org for you to download and work with in your area. Individuals and organizations can visit our Web site to support it, adopt it as a focal point for their work and use it as an educationawl instrument and guide to help hospitals and other birth facilities in their areas improve their maternity care. Hospitals can work to achieve the 10 Steps as a means to providing optimal motherbaby care.
For more than 30 years, a significant part of the womens health movement has repeatedly asked for a re-appropriation of womens bodies while birthing, coupled with a request for the de-medicalization of this important event for women. More recently, womens rights have been emphasized in the domain of sexuality and reproductionfor instance, the right to decide, to be adequately informed and to have bodily integrity. In June 2009, the UN Human Rights Council passed a landmark resolution (7) that recognizes preventable maternal mortality and morbidity as a pressing human-rights issue that violates a womans rights to health, life, education, dignity and information.(8) More recently, Amnesty International released a report entitled Deadly Delivery: The Maternal Child Health Crisis in the USA demonstrating that even resource-rich countries have not put practices in place that treat women with dignity, respect and appropriate care.(9)
To recap, birth itself is not a human right, but humane and evidence-based care during birth is a human right, just as humane and evidence-based care is a human right for every person who seeks health care. Its time for all women, men, midwives, nurses, doulas and care providers to see birth as a human rights issue.
Editors note: At Midwifery Todays upcoming conference in Strasbourg, France, which is the seat of the European Court of Human Rights as well as the European Parliament, we plan to thoroughly examine these issues and to make plans for replacing current, harmful birth practices with supportive, evidence-based care. Our conference theme is Birth Is a Human Rights Issue. Let us commit to an optimal birth for every mother and baby. We hope to report back to you about this event. Please consider joining or sponsoring us in our continuing efforts to create change and educate the world about these ongoing human rights violations. Please share this information with your network and colleagues, and help us to spread this important movement around the world. For more information about this event, please visit our Web site at www.midwiferytoday.com/conferences/Strasbourg2010/.
(Derived from the International MotherBaby Childbirth Initiative)
Our thanks to Marcia Westmoreland for her work on extrapolating these MotherBaby Rights from the text of the IMBCI.
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