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Mother Friendly Hospital InitiativeMother Friendly Hospital Initiative
Mother Friendly Hospital InitiativeA scientific and theoretical approach
34Th Symposium of the
CROATIAN ASSOCIATION OF MIDWIVES
6-8 May 2010, Vodice
Joeri VermeulenHead of midwifery, Erasmus University College Brussels
Board Vlaamse Organisatie van VroedvrouwenBelgian Midwives Association
European Midwives Association
Flanders + Wallonia = BelgiumFlanders + Wallonia = Belgium
Brussels, ... capital of EuropeBrussels, ... capital of Europe
Current situation in midwifery/obstetrics (US, Europe)
MFCI What? Who’s initiative? Philosophical cornerstones of mother friendly care 10 Steps of the MFCI Points of discussion-not limited Evolution to Motherbaby Childbirth Initiative? Other initiatives to make maternity care more MF
Strategies to make our birthing centers “mother friendly”?
Content
Induction (41%)/Augmentation (55%) Intravenous line (80%) EFM (94% continuity) Restrictions movement (75%),
eating (85%), drinking (57%)
Epidural (71% of vaginal births) Urinary catheter (43%) Instrument delivery (39%)/episiotomy (25%) Cesarean Section (32%)
Listening to Mothers (2006)
Current situation in midwifery/obstetricsFacts from the USA
Maternal mortality is 4 x ≥
for African-American women than for
Euro-American women
In countries where midwives are in charge of normal births=>better perinatal outcomes (Scandinavia)
A lot of procedures (high costs and inferior outcomes) are not evidence based
Increased dependence on technology=>diminished confidence in women’s ability to give birth without intervention
Only a fraction of US mothers are fully breastfeeding their BB’s at the age of 6 weeks
No equal access to health care resources for women from disadvantaged population groups
Current situation in midwifery/obstetricsFacts from the USA
http://www.youtube.com/watch?v=4DgLf8hH Mgo
The business of being born, 2007USA only???
Non-compliance with evidence based midwifery/obstetrics(Enkin et al, 1992, NICE 2007 guidelines, RCM 2008 guidelines, WHO 1992 guidelines, …)
Shaving Enema IV Fluids Withhold of oral nourishment AROM
Current situation in midwifery/obstetricsEurope
Non-compliance with evidence based midwifery/obstetrics
EFM in low risk pregnancy Indiscriminate use of episiotomy
Widespread use of pharmacological methods of pain relief
Increase SC decrease VBAC Inadequate support for BF …
Current situation in midwifery/obstetricsEurope
Is the first and only consensus document on maternity care in the US, 1996
It is an evidence-based mother-, baby-
and family friendly model
Focus on prevention and wellness as alternatives to high cost screening, diagnosis and treatment programs
“Safe” care; means that care is provided through EB practices that minimizes the risk of error and harm and support the normal physiology of labour and birth
Effective care; the care expects benefits and is appropriate to the needs of the woman and her baby based on sound evidence
>=<BFHI Launched 1991 WHO/Unicef initiative
Mother Friendly Childbirth InitiativeWhat?
Evolved from the collaborative efforts of individuals (individual providers, researchers, scholars, advocates, activists, consumers, mothers and family members) and national organisations (26) focused on pregnancy, birth and breastfeedingNGOFocus on care and wellbeing of mothers, babies, familiesMission:
To promote wellness model of maternity care That will improve birth outcomes That will substantially reduce costs
MFCIWho’s initiative?
Coalition of Improving Maternity Services
1
MFCICIMS
www.motherfriendly.org
Normalcy of the birthing process Empowerment Autonomy Do not harm Responsibility
Based on this principles 10 steps where set up to support, protect and promote mother-friendly maternity servicesThose 4 cornerstones are applicable on each step
MFCIPhilosophical cornerstones of mother-friendly
care
‘Increased medicalisation of birth has had a profound effect on midwives and doctors who work in an atmosphere of tension and potential disaster without understanding first how women function when supported and encouraged to give birth normally’(Beech, 2001)
Some tougths about ‘Normalicy’
Treat every woman with respect and dignity
Possess and apply routinely midwifery knowledge and skills that optimize the normal physiology of birth
Inform the mother of the benefits of continuous support during labour
and birth and affirm her right
to receive that support from companions of her choice
Provide evidence-based practices proven to be beneficial
10 steps of the MFCIFor mother-friendly hospitals, birth centers
and home birth services
Avoid potentially harmful procedures and practices
Implement measures that enhances wellness and prevent illness and emergencies
Provide access to evidence-based skilled emergency treatment
Provide a continuum of collaborative care with all relevant health care providers, institutions and organisations
Strive to achieve the
BFHI 10 steps to successful
BF
10 steps of the MFCI
Freedom of Movement
Throughout Labor
No Routine
Interventions
Continous Labour support
Non-Supine Positions for Birth
Step 6 no routine interventions-% set to get the label MF
<20% episiotomy <10% induction of labour
for medical reasons
<10% SC (no referral hospitals) <20% (referral hospitals)
Min. 60% VBAC
10 steps of the MFCI
Evidence based practices more to include
Unrestricted access to food and drink as she wishes during labour
‘Techniques for turning the baby in utero
and for vaginal breech delivery’
‘Facilitate immediate skin to skin …’.
‘Allow adequate timing for cord blood to transfer to the baby for blood volume, oxygen, nutrients it provide’
As many birth companions as woman wish?
Points of discussion in my countryNot limited, …
(National Guideline on ‘Normal intrapartal care’)
Avoid potentially harmful procedures (no scientific support for routine use, potential harms)
Witholding
food and wather Routine EFM Pharmacological pain control Lithotomy
positions
Caregiver directed pushing …
Points of discussion in my countryNot limited, …
New:
Mother and baby constitute an integral unit during pregnancy, birth and infancy
And should be treated as such, as the care of one significantly impacts the care of the other
This unit is referred as the ‘Motherbaby’
Evolution to Motherbaby Childbirth InitiativeEvolution to
International Motherbaby
Childbirth
Initiative in Global Context=>Dealing with goal 1,3,4,6 UN Millennium Development Goals
Motherbaby Childbirth Initiative?(implicit criticism on separation BFHI and MFCI)
Normal Labour
Clinical Pathway (Welsh Assembly Government,
2002) NICE guidelines
Antenatal care, 2008 EFM, 2001 Intrapartum
care 2007
RCM guidelines
Evidence-based guidelines for midwifery-led care in labour, 2008
Association for improvements in the Maternity Services since 1960 (Beech, 1997)
Working towards normal birthProviding independent support and information about maternity choicesRaising awareness of current research on childbirth and related issues
…
Other initiativesExamples from the UK
How to integrate mother-friendly childbirth practices into maternity services?
National guidelines (in the context of authorized national and/scientific body)
Integration with BFHI (Unicef/WHO) Quality label Stakeholders consultation/communication
Involve women!!!
“Are women who are used to being in control of their lives unable to relinquish this control, and so interfering with their ability to give birth?”(Savage, 2001)
Introspection
When tempted to intervene, try sitting on your hands for 10 minutes! (Sutton, 1991)
Strategies to make our birthing centers “mother friendly”?
Network as an important tool to facilitate changes, Network as an important tool to facilitate changes, …… European Midwives AssociationEuropean Midwives Association International Confederation of MidwivesInternational Confederation of Midwives Initiatives to take (European projects, thematic networks, Initiatives to take (European projects, thematic networks, …….).)
‘Be the change you want to see in the world’
Mahatma Gandhi(1869-1948)
Strategies to make our birthing centers “mother friendly”?
“One of the things I learnt when I was negotiating was that until I changed myself I could not change others ”
Nelson Mandela (°1918)
MIDWIFERY LED CARE A scientific and theoretical approach
34TH Symposium of the
CROATIAN ASSOCIATION OF MIDWIVES
6-8 May 2010, Vodice
Joeri VermeulenHead of midwifery, Erasmus University College Brussels
Board Vlaamse Organisatie van vroedvrouwenBelgian Midwives Association
European Midwives Association
The World Health Organisation:
“Midwives are the most appropriate primary
carers for women during pregnancy and childbirth
as these are normal biological processes where
most women will achieve successful outcomes if
given support and patience”
INTRODUCTION
“… The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant…”
The International Confederation of Midwives:Definition of the MidwifeBrisbane, Australia, 2005
INTRODUCTION
“…The midwife as first point of contact …”
Maternity Matters, 2007
UK
INTRODUCTION
Introduction
Midwifery led care
Research results
Challenges
CONTENT
Worldwide medicalisation of low-risk pregnancies:
Canada, USA, Italy, …: CS rates >20% (Morano et al., 2007)
Flanders: CS rate 2007: 19%
(SPE, 2007)
CS rate 2008: 19,5%
(SPE, 2008)
Only 6% of deliveries in Flanders occured ‘physiological’(delivery without induction, spontaneous onset, without EA, without VE/forceps, without CS, without episiotomy) (SPE, 2008)
INTRODUCTION
Normal birth rate (if defined as with no clinical intervention)
UK 16,9% primigravid 30,1% multigravid
BUT 1/3 of births recorded as spontaneous underwent induction or augmentation of labour (Downe et al, 2001)
Some tougths about ‘Normalicy’
Remarkable variation (factor 3-4) between different hospitals in Flanders for SC, VE/forceps, EA, and induction of labour.(Not typical for my country!)(SPE, 2008)
Researchers tried to identify influential factors for those differences in ‘medicalisation’
between different hospitals in a
country. (Villar et al., 2001; Mead & Kornbrot, 2004; Mead et al., 2007)
INTRODUCTION
Intrapartal risk perception Culture in the hospital/ward
Medicalisation
Increased medicalisation
Increased awareness of ‘informed choice’, patient
satisfaction, patient safety, family-centered care
Health carers, consumers and policy makers are
more aware/interested in midwifery models of care
INTRODUCTION
Midwifery led care (MLC) is an interdisciplinary model and centralises woman, child and familyCharacteristics:
Perinatal continuity of care and caregiver
Midwife is in lead
Low risk only!
Referral procedure
In hospitals or birth centers
Separate form ‘traditional’
obstetric unit (not always, this can influence, …)
Focus on physical, psychological, and social wellbeing of the family
Individualized care, health promotion, ….
Woman centered care
Options of informed choice (birthplan?)
Avoiding of unnecessary interventions(Rooks,1999; Morano et al., 2007; Hatem, 2008; Sandall et al., 2009)
MIDWIFERY LED CARE
Different models of care in MLC
Team midwifery/group practice care
6-8 midwives provide together whole care to +/-
35 women
They attend births in hospitals, birth centres and at home
Caseload midwifery
One to one case loading
Time consuming-Always on call
…(Morano et al., 2007; Hatem, 2008; Sandell et al., 2009)
MIDWIFERY LED CARE
Cochrane review (Hatem et al., 2008 )
Team midwifery en caseload midwifery vs. traditional
models of care
11 RCT’s
>12.000 women
RESEARCH RESULTS
Significant differences MLC vs traditional models of care (Hatem et al., 2008 )
↓
Antenatal hospitalisation
↓
Episiotomy
↓
VE/forceps
(no differences in rates of SC)
↓
EA
↓
Foetale death <24 weeks
(no differences >24 weeks)
RESEARCH RESULTS Cochrane review, 2008
Significant differences MLC vs traditional models of care (Hatem et al., 2008 )
Duration of neonatal admission
Breastfeeding (starters)
Locus of control of the mother
RESEARCH RESULTSCochrane review, 2008
RESEARCH RESULTSIreland, 2009
Research results:
MLC is as safe as traditional care
MLC results in less interventions
Higher patient satisfaction if MLC
RESEARCH RESULTSIreland, 2009
Trend to higher cost effectiviness
Results from UK (Osborne, 2010)
NHS tariff shows that midwifery care is economical
Average cost of midwife care and birth= £
1,000
Average cost of doctor led care and delivery by forceps or ventouse= £
1,600
Average cost of doctor led care and delivery by CS= £
3,000
Where selection is applied midwifery care is safe for 50-60% of the UK population
RESEARCH RESULTSUK, 2009
Semi structured interviews with
midwives in MLC and
traditional settings More continuity of care
Less procedures and protocols
Less routin interventions
More women/family centered care
More mobility of women
More deliveries in vertical position
RESEARCH RESULTSGermany, 2004-2007
Semi structured interviews with
women in MLC and
traditional settings Older women in MLC group (reason?)
More BF (starters)
More non-pharmacological interventions for pain relief
Most of women (72%) knows the midwife who will be present at
birth
More satisfaction of women
RESEARCH RESULTSGermany, 2007-2010
Advantages :
Medical and psychological advantages for mother and child Know their midwives
Choice of where to access
More LOC
More satisfaction
Advantages for midwives? Development of skills
Autonomous practice
Flexible working
Satisfaction of supporting women through the whole process of birth
Advantages for health organisation?
Advantages for health system?
RESEARCH RESULTSGeneral taughts
How trigger the implementation
System of health care organisation (private hospitals, reimbursment
system, on micro level: 1/1 care, archtitectural changes, …)
Is MLC what women/society wants? (private health care-higher
status, confidence in midwives, fear of what can hapen,
social/sociological influences …)
Changing childbirth initiative, 1993
Maternity matters, 2007
Government tool
Midwife as first point of contact
CHALLENGES
How trigger the implementation
Resistance to change (fear, autonomy, skills, juridical aspects,
…)
Necessity to multidisciplinairy collaboration (management, doctors,
and women)
EU Directive 2005/36/EC
Professionalisation of midwifery, education, research-creation of
own body of knowledge, evidence based work, …)
Networks
…..
CHALLENGES
“Achieving change to enhance outcomes of maternity care is
a complex undertaking. Nevertheless, it is a challenge we
have to address if women are to receive safe, high-quality
care associated with the best possible outcomes provided by
midwives who feel confident and skilled to provide the best
possible care” (Bick, 2009)
CHALLENGES
“A pessimist sees the difficulty in every opportunity; an optimist sees the opportunity in every difficulty”
Winston Churchill 1874-1965
We wish Croatian midwives all the We wish Croatian midwives all the best for future, best for future, ……
Questions?Questions? More information???More information???
www.campusjette.com
www.vlov.be
www.belgianmidwivesassociation.eu
www.europeanmidwives.eu
