The Problems: Too Much Too Soon and Too Little Too Late
Globally, there is the problem of the over-medicalization of childbirth, but there is also the problem of the under-utilization of lifesaving care, and marginalized people often suffer needlessly from lack, rather than overuse, of health care during pregnancy, birth, and postpartum recovery. This quote from Miller et al. (2016) in The Lancet sums up the current global problems with obstetric maternity care:
On the continuum of maternal health care, two extreme situations exist: too little, too late (TLTL) and too much, too soon (TMTS). TLTL describes care with inadequate resources, below evidence-based standards, or care withheld or unavailable until too late to help. TLTL is an underlying problem associated with high maternal mortality and morbidity. TMTS describes the routine over-medicalisation of normal pregnancy and birth. TMTS includes unnecessary use of non-evidence-based interventions, as well as use of interventions that can be lifesaving when used appropriately, but harmful when applied routinely or overused.
Melissa Cheyney and Robbie Davis-Floyd (2020) have recommended replacing the TMTS/TLTL care dichotomy with RARTRW care—the right amount at the right time in the right way, for how care is provided matters as much as what care is provided and when.
Another problem is that individual providers and facilities often function without a cohesive framework or set of checklists to be able to judge if what we are doing during childbirth really is in the best interests of the mother, baby, and family. The results are that the homebirth community is not well understood by local hospital providers, and that policies within and among hospitals vary widely regarding home-to-hospital transfers, and also regarding the use of interventions for both normal and complicated births. The US has an abysmal rating for maternal mortality among high-resource nations, ranking near the bottom, and community births (births in homes and in freestanding birth centers) account for only 2% of all births nationwide—a rise from the 1.26% rate prior to the coronavirus pandemic (Eugene Declerq, epidemiologist, personal communication with Robbie, Feb. 2022), which resulted in many pregnant women fearing hospital contagion and separation from their partners and/or doulas, and therefore choosing community midwifery care (Davis-Floyd, Gutschow, and Schwartz 2020; Gutschow and Davis-Floyd 2021).
Care that is “too little, too late” is still a problem at times in all birth settings, and “too much too soon” is not limited to any one place either; overmedicalization is seeping into some midwifery practices both within hospitals and within community birth. Without a clear mandate, it is hard to imagine how everyone attending births will get on the same page.
The Solution: The International Childbirth Initiative
We believe we have the solution right in front of us, laid out in a simple framework that midwives, doctors, or other birth practitioners can use in home births, birth centers, or hospitals. The International Childbirth Initiative (ICI): 12 Steps to Safe and Respectful MotherBaby-Family Maternity Care makes it easy to adopt beneficial changes to childbirth practices. The ICI was launched in 2018 when the International Federation of Obstetricians and Gynecologists (FIGO—its acronym in French) merged their set of 10 Steps with the 10 Steps of the pre-existing International MotherBaby Childbirth Initiative (IMBCI) to create clear guidelines for keeping childbirth safe, respectful, and evidence-based. (Robbie Davis-Floyd, co-author of this article, spent two months wordsmithing that merger, and ended up with 12 steps, because each of the prior initiatives contained important Steps that the other did not.) The ICI has now been endorsed by FIGO, the International Confederation of Midwives (ICM), the Harvard T. Chan School of Public Health, the White Ribbon Alliance, Lamaze International, DONA International, the Society of Obstetricians and Gynaecologists of Canada (SOGC), the American College of Nurse-Midwives (ACNM), the Midwives Alliance of North America (MANA), Midwifery Today, the International Pediatric Association (IPA), the International Council of Nurses (ICN), Mercy In Action, the Bumi Sehat Foundation, and many more. (To see a list of all ICI endorsers, go to www.icichildbirth.org.)
Everyone wins with this initiative; obstetricians, midwives, and nurses can agree on things that have already been agreed upon by their international or national organizations (as shown in the list of endorsers above). The 12 steps are easy to understand and measurable. Yet arguably, the biggest winners are the chief stakeholders in childbirth—the “MotherBaby-Family.” Everything should revolve around their needs, and with the implementation of the ICI 12 Steps to Safe and Respectful MotherBaby-Family Maternity Care, everything does.
The power of the ICI 12 Steps is that they address both crises in maternity care—TMTS and TLTL—and can be used in the US and around the world to help obstetric practitioners and midwives provide RARTRW care (the right amount at the right time in the right way). Step 1 addresses respectful care; Step 2 addresses accessibility to care for all; and Steps 3–8 are about keeping childbirth normal by protecting the physiologic process from too much intervention or medicalization while optimizing wellness. To address serious complications that can arise during childbirth, Step 9 assures that practitioners are capable of providing excellent emergency care when needed. Steps 10 and 11 are about working well together as a birth team and working collaboratively with other providers outside of “our” team, for the best chance of having good outcomes, no matter what happens during labor. Step 12 includes the 10 Steps of the Baby-Friendly Hospital Initiative, which provide best practices in supporting breastfeeding. (See Figure 1 for a summary of the 12 Steps of the ICI.) For each Step, progress and compliance are measured using patient surveys, interviews, and observations of the care provided, which can be carried out by involved local people. Researchers are needed to study the implementation process, identify any barriers to it, and suggest solutions. (If you are interested in conducting such research, please contact Robbie at: email@example.com; Debra Pascali Bonaro at: firstname.lastname@example.org; and/or André Lalonde: email@example.com.)
Again, what you see in Figure 1 above is a summary of the 12 Steps. The full ICI document, which can be found on the ICI website, provides its Foundational Principles (some of which we also provide below), a comprehensive explanation of each Step, and a set of indicators that can be used to measure compliance with each Step. The website also contains recorded webinars on each step, taught by global experts in maternity care (Vicki Penwell, co-author of this article, taught the webinar on Step 2). Everything we need to understand the concepts and to watch the webinars is provided at www.icichildbirth.org. According to André Lalonde (in press), the long-term Chair of the ICI Executive Committee:
The ICI is currently being implemented in large hospitals and smaller facilities around the world. The countries with accepted facilities include Austria, Brazil, Canada, Chile, Colombia, Fiji, India, Indonesia, Kenya, Mongolia, Papua New Guinea, the Philippines, the Solomon Islands, Trinidad, Turkey, and the United States. Countries that are initiating implementation (applications in progress) include Argentina, Australia, Burkina Faso, China, the Czech Republic, Germany, Honduras, Mexico, Nigeria, and Uruguay.
One of the great strengths of the ICI implementation process is that in every case, community members are included and involved in that process, often serving as monitors to ensure that the implementing facility is sticking to its commitment to implement the ICI 12 Steps. To date, there are 60 ICI implementation sites and their number is growing!(1)
The Foundational Principles of the ICI
The following principles are the foundation of the International Childbirth Initiative (ICI): 12 Steps to Safe and Respectful MotherBaby-Family Maternity Care. These principles are taken directly from the text of the ICI, which, again, can be found at www.icichildbirth.org. Due to space considerations, we include only three of the seven Foundational Principles, just to give you an idea of what they are like.
Advocating rights and access to care
- Women’s and children’s rights are human rights and must be ensured in all settings and circumstances, including humanitarian and conflict settings. Every woman and newborn, regardless of background, social and educational status, citizenship, age, and health status has the right to access well-staffed and equipped and free or fairly-priced maternal and newborn health services that provide quality care from skilled attendants. Higher rates of maternal and newborn mortality and morbidity resulting from inadequate access to essential care services and poor quality of care are unacceptable.
Ensuring respectful maternity care
- Consideration, respect and compassion for every woman and newborn should be the foundation of all maternity care, even in the event of complications.
- Every motherbaby should be protected from disrespectful or violent practices of any kind, as well as from infringements on their right to privacy.
Protecting the MotherBaby-Family triad
- The MotherBaby-Family refers to an integral unit during pre-conception, pregnancy, birth, and infancy influencing the health of one another. Within this triad, the motherbaby dyad remains recognized as one unit, as the care of one significantly impacts the other. The addition of family to this unit conveys the importance of husbands, partners, and the social and/or community family structure in which a child in conceived, born, and raised, and emphasizes that maternal care activities and systems need to fulfil the needs of the MotherBaby-Family triad in order to achieve the full potential of safe and respectful maternity care.
- Throughout the entire continuum of maternity care, the MotherBaby-Family should be actively engaged in care provision, aspiring for shared decision making, with the woman ultimately being the decision maker.
The Way Forward: Implementing the ICI
Finally, we have a way forward. We are passionate about staying present in the struggle to improve maternity care and about modeling for the next generation of midwives and doctors how to find their balance among all the options and attitudes pulling them in opposing directions. There is clarity to be gained from having a well-researched template of best practices in maternity care to guide our paths, and the ICI 12 Steps provide that template for every birthworker, regardless of setting.
You can begin right away by applying to be officially recognized as an ICI implementor via the ICI website. The ICI Executive Committee welcomes all health facilities or individual practices that are attending deliveries to apply to partner with them and to implement the 12 Steps of the ICI. Whether you immediately meet all 12 steps or have room for improvement, the team at ICI gives you all the help, guidance, and coaching you may need to grow into an example of excellence in your local or regional birth community, as the ICI 12 Steps apply to facilities both large and small. For example, Mercy In Action has managed to fully implement all 12 steps both in our US birth center in Idaho and in all our birth centers in the Philippines, even while attending births in disaster zones in tents with no running water, as have midwife Ibu Robin Lim and the midwives from Bumi Sehat—an NGO that Lim founded in Indonesia. Like Mercy In Action, Bumi Sehat has provided safe and respectful maternity care that follows all 12 Steps of the ICI both in their birth centers and in multiple disaster zones, thereby providing RARTRW care to all of their clients, and demonstrating that high-tech obstetric care is rarely necessary for safe birth attendance (2).
Yet we do not wish to give you the impression that the ICI is only for use in low-resource countries that provide TLTL care. Much to the contrary, it is also sorely needed in high-resource countries like the US that provide TMTS—and also sometimes TLTL—care. ICI implementation can be as equally valuable for small midwifery practices as for tertiary care hospitals, as it can help even community midwives to stay on track in practicing the midwifery model of care, which is another foundation of the ICI. The two smaller practices in the US that are presently implementing the ICI are the Authentic Birth Center, an FBC in Wisconsin run by midwife LaNette McQuitty, CPM, LM, and The Birth Place in Florida, run by midwife Jennie Joseph, CPM, LM. (For a full description of her practice, which supports low-income and marginalized women to have safe and well-nurtured pregnancies and births, see Joseph 2021). Many more applications for ICI implementation from US maternity care practices are needed, and we urge you, our readers, to take the following action steps.
First, apply to get the ICI designation for where you work as a midwife or other maternity care practitioner. Then share the website www.icichildbirth.org with your local hospital(s) and ask them to consider applying along with you to become an ICI implementing partner. Imagine what it would mean for birthing parents to experience this model that places them at the center, regardless of where they choose to give birth. Imagine the difference it would make in home-to-hospital transfers if you both shared an understanding of the value of the ICI 12 Steps, which include Step 11:
Provide a continuum of collaborative maternal and newborn care with all relevant health care educators, providers, institutions, and organizations … Specifically, individuals … offering maternity-related services should collaborate across disciplinary, educational, cultural, and institutional boundaries to provide the MotherBaby with the best possible care within a functional team, recognizing each other’s knowledge and experience [and fostering continuity of care].
With many international organizations, obstetricians, and midwives now promoting the ICI, these are real possibilities.
Midwives, let’s lead the way and believe that if enough birth providers and facilities implement the International Childbirth Initiative: 12 Steps to Safe and Respectful MotherBaby-Family Maternity Care, a movement toward better birth is possible on a scale we have not yet seen!
- Cheyney, M, and R Davis-Floyd. 2020. “Birth and the Big Bad Wolf: A Biocultural, Co-Evolutionary Perspective, Part 2.” International Journal of Childbirth 10(2): 66–78.
- Davis-Floyd, R, K Gutschow, and DA Schwartz. 2020 “Pregnancy, Birth, and the COVID-19 Pandemic in the United States.” Medical Anthropology 39(5): 413–27.
- Davis-Floyd, R, et al. 2021. “Effective Maternity Disaster Care: Low Tech, Skilled Touch.” In Sustainable Birth in Disruptive Times, eds. Kim Gutschow, Robbie Davis-Floyd, and Betty-Anne Daviss. Switzerland: Springer Publishing, pp. 261–76.
- Gutschow, K, and R Davis-Floyd. 2021. “The Impacts of COVID-19 on US Maternity Care Practitioners: A Follow-up Study.” Frontiers in Sociology 6:655401: 1–18.
- Joseph, J. 2021. “There’s Something Wrong Here: African-American Pregnant Women and Their Babies Are at Greatest Risk in the USA.” In Birthing Models on the Human Rights Frontier: Speaking Truth to Power, eds. Betty-Anne Daviss and Robbie Davis-Floyd. Abingdon, Oxon: Routledge, pp. 131–44.
- Lalonde, A. In press. “How an Obstetrician Promoted Respectful Care in Canada and the World.” In Obstetricians Speak: On Training, Practice, Fear, and Transformation, eds. Robbie Davis-Floyd and Ashish Premkumar, Chapter 13. New York: Berghahn Books, forthcoming 2023.
- Miller, S, et al. 2016. “Beyond Too Little, Too Late and Too Much, Too Soon: A Pathway Towards Evidence-Based, Respectful Maternity Care Worldwide.” The Lancet 388(10056): 2176–192.
- To obtain the names of the implementing sites and of the contact persons for those sites, write to Robbie at firstname.lastname@example.org.
- For descriptions of Mercy In Action’s disaster zone care and of the disaster care provided by midwife Robin Lim and her Bumi Sehat team, see Davis-Floyd et al. 2021. Vicki Penwell also notes here that “the results we achieved, even in tents with no running water or in near-destroyed homes, were better than the national averages in the countries where we and our teams provided such care.”