Most people now acknowledge that close physical proximity between mothers and babies during the first hours, days, weeks and even months of life is ideal for both. We know that being skin-to-skin encourages the baby’s oxygen levels to remain stable, that it regulates her temperature, that it encourages bonding between the two, that it stimulates milk production in the mother’s breasts and that babies held skin-to-skin for long periods tend to cry much less often (and have lower levels of stress hormones as a result). We know that breastfeeding on-demand helps both mother and baby adapt to life after birth; that room- and even bed-sharing helps everyone get more sleep, can prevent SIDS and make breastfeeding easier; that picking up a crying baby rather than letting them ‘cry it out’ keeps stress levels low and tends to lead to less anxiety later in life. Basically, the goal in all of these things is to allow the newborn to live outside of the womb in a manner that resembles life in the womb as closely as possible. Human babies are born essentially premature when compared to other mammals. While the calf can walk at birth and the baby chimp can cling to it’s mother’s back while she climbs, human babies are still essentially foetal. Why? Simply put, we walk upright, which affects the size and shape of our pelvic bones and we have big brains, which require large skulls to keep them in. In order for our human skulls to fit through our human pelvises (which they do very well, thank you very much – remember, as Ina May says, “Your body is not a lemon.”) we must be born early relative to other mammals. This works out ok, as long as we are prepared to care for what is essentially a foetus living outside of the womb. Doing so is even more demanding than pregnancy and requires support systems, maternity leaves, lots of encouragement and the ability to pick oneself up again time and time again (i.e. self-compassion). I have written before about the importance of community and social support systems for new parents but today I am thinking about the process of labour and birth and how they affect both mom and baby (or, motherbaby as many people are now referring to newborns and their moms to signify the importance of caring for them as a single entity). We accept that what happens after birth affects both mother and baby, but the evidence also shows that how a mother is treated prenatally and during labour and birth affects both individuals as well. So what does it mean for a hospital to be considered “mother-friendly” or “baby-friendly” and why are these two separate sets of considerations?First, I’ll briefly explain the Mother-Friendly Childbirth Initiative (MFCI). This set of principles and guidelines is laid out by the Coalition for Improving Maternity Services (CIMS). I am not going to go through the details here, because it is a lengthy document, but you can read the entire thing on the CIMS website. CIMS is an American organization, aimed specifically at improving maternity care in the US, but they draw their evidence from organizations all over the world including the Canadian Paediatric Society, the International Lactation Consultant Association, the WHO, etc. They are ratified and endorsed by organizations such as the American College of Nurse-Midwives, the Association of Women’s Health, Obstetrics and Neonatal Nursing, Doulas of North America, The Farm, La Leche League International, Midwives Alliance of North America and many, many others. The principles that underpin the MFCI are:
- normalcy of the birthing process
- do no harm
Those five principles (which I would encourage you to read the details of via the link I provided above) give rise to ten steps which support, promote and protect maternity services in hospitals, birth centres and at home births. These steps include, providing access to support from partners and doulas; access to midwives; access to descriptive and statistical information; culturally competent care; freedom of movement; collaboration and consultation among caregivers; eliminating the routine use of procedures not supported by evidence and maintaining intervention rates at appropriate levels (including induction, episiotomy, caesarean and VBAC rates); educating staff on non-medical approaches to pain relief; encouraging all mothers and families to touch, breastfeed, hold and care for their babies; discouraging non-religious circumcision of newborns and striving to achieve WHO/Unicef Baby-Friendly status.
Second, the Baby-Friendly Hospital Initiative is, as suggested above, a program developed by the World Health Organization and Unicef and is controlled by national breastfeeding authorities using global criteria that can be applied in every country. In order to be recognized as a baby-friendly hospital, a facility must:
- not accept free or low-cost breastmilk substitutes, feeding bottles or teats
- implement the ten steps for supporting successful breastfeeding
Those ten steps are:
- have a written breastfeeding policy that is routinely communicated to all health care staff
- train all health-care staff in necessary skills for implementing this policy
- inform all pregnant women about the benefits and management of breastfeeding
- help mothers initiate breastfeeding within one half-hour after birth
- show mothers how to breastfeed and maintain lactation, even if they should be separated from their infants
- give newborn infants no food or drink other than breastmilk, unless medically indicated
- practice 24-hour a day rooming-in
- encourage breastfeeding on-demand
- give no artificial pacifiers or teats to breastfeeding infants
- foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic
Ok, now that we have a reasonable understanding of both the Mother-Friendly Initiative and the Baby-Friendly Initiative, I can (finally!) get to my point. In the MFCI, we see references, of course, to the treatment of the mother prenatally, in labour and postpartum, as well as reference to the newborn, specifically including striving to achieve baby-friendly status according to the WHO/Unicef guidelines. If we consider the motherbaby dyad – that is, the notion that the mother and baby are distinct, yet interdependent beings and that this interdependence is vital to both – this makes perfect sense. In order to be ‘friendly’ to the mother, we must also be ‘friendly’ to the baby. Supporting a mother in achieving her goals in labour, but also in caring for, feeding and bonding with her baby is essential to this. It is also worth noting, that breastfeeding in and of itself is also beneficial to mothers, reducing rates of breast cancer, osteoporosis, alzheimer’s and other health problems.
In stark contrast, the BFHI focuses only on the baby or on the mother in terms of her care and feeding of her baby. No mention is made of interventions during labour, no attention is given to her freedom of movement, her access to support people, respect for the mother as demonstrated by provision of information and the right to informed consent, non-medical pain relief, etc. Given that current evidence shows that interventions such as induction and caesarean section can have significant impacts on breastfeeding rates, that the presence of a doula during labour increases the chances of successful breasteeding and that birth trauma manifesting in postpartum depression can massively affect a woman’s ability to nurse and bond with her baby regardless of breastfeeding success, does this not seem troubling? How can we say that we are acting in the best interest of a being (the baby) if we are not sure we are acting in the best interest of the being to whom she is necessarily and vitally interconnected?
I believe that if we want to be truly baby-friendly, we must be mother-friendly as well and vice versa. I would love to see the WHO/Unicef Initiative revised to include elements of mother-friendly practice or specific reference to the CIMS MFCI. Perhaps we should be striving to create the Motherbaby-Friendly Childbirth Initiative, acknowledging that we can’t really have one without the other.
It seems to me that putting the needs of the child above the needs of the mother is a chronic problem in our society, one that benefits no one, but which points to a lack of respect for women as a group. We see this all the time when women who are upset by or even traumatized by the circumstances surrounding their births are told, “at least you have a healthy baby”. Women’s experiences of birth matter for their own sake, but even if society as a whole can’t accept that, perhaps we can at least make changes that will improve those experiences incidentally by properly acknowledging the interconnectedness of mother and baby, that is, respecting the motherbaby dyad.
What do you think? Can a hospital, birth centre or caregiver be truly committed to the needs of the child without first being committed to the needs of her mother throughout pregnancy, labour, birth and the postpartum period?
photo credit: Martin Gommel via photopin cc
This is so right on! I found your article as I am sitting here writing a personal statement for my medical school application. These exact principles are the things I want to focus on as an obstetrician, and I’m having the hardest time expressing them in my statement without coming across as negative and critical of American obstetrics today. I love these thoughts and really appreciate the article! Thank you.
Thank you Lauren! Good luck with your med school application. It sounds like we could use more OBs like you 🙂