How a Checklist Promotes Human Rights in Childbirth: The International MotherBaby Childbirth Initiative

Editor’s note: This article first appeared in Midwifery Today, Issue 119, Autumn 2016.
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The danger faced by women giving birth is real. While things have improved over the past two decades, still today, a mother dies every two minutes from pregnancy- and childbirth-related causes somewhere on this globe. The maternal mortality rates vary greatly by country, with a total of 98% of newborn deaths and 99% of maternal deaths occurring in low- and middle-income countries. The vast majority of the burden of deaths is spread fairly equally between Asia and Africa. This is not just a health issue but a human rights issue and a social justice issue as well.

When I began working in Asia 25 years ago, no one was talking about the things I was seeing. I saw shocking physical and emotional abuse in hospitals and at home, at the hands of those who should be helping, not harming, the mother in labor.

Now abuse and disrespect of women in labor is well-documented and discussed in groups as diverse as the White Ribbon Alliance, Amnesty International, Harvard University and in the pages of the International Journal of Gynecology and Obstetrics. Midwifery Today magazine has taken a lead in publishing stories advocating for human rights in childbirth, while hosting conferences with the same theme. This is an encouraging trend, for acknowledging and documenting a problem is the first step. But it is only the first step; the time is now for concrete action.

It has become a matter of life and death that we treat pregnant women better if we want better outcomes.

The problem is that as women’s groups all over the world are joining with human rights groups to fight for respect during childbirth, health professionals, public policy makers and lawmakers are fighting to make childbirth safer. And those goals are often seemingly at odds.

It is important every now and then to take a step back and acknowledge that everybody wants the same thing: healthy mothers and healthy babies who survive birth and thrive. Midwives, doctors and nurses, indeed entire governments and many NGOs, are working around the world to help ensure that every woman and baby survives birth. But recently, the discussion has gone deeper, and many are concerned that human rights not be trampled while rushing to save lives.

As someone who has witnessed decades of human rights violations in my work as a midwife among the poor in Southeast Asia and Latin America, as well as in America, I know I am not alone in desperately wanting things to be different for women, especially the poor and disenfranchised who suffer the most. It has become a matter of life and death that we treat pregnant women better if we want better outcomes.

But long-standing attitudes detrimental to pregnant women are hard to break, especially in countries where women in general have few rights. A system of excess medicalization can be as dangerous both physically and emotionally as under-treatment and neglect in childbirth, and rules and policies as well as traditions can violate the fundamental human rights of women, babies and entire families.

This article is to give hope to all the readers who have been deeply troubled by what they have seen firsthand or been told about the situations where birth rights and human rights both seem to be negligible and where often one senses a hopelessness and despair that things will never get better for women in childbirth. In the face of such a seemingly intractable problem as human rights violations, how does a checklist make a difference?

There is an amazingly simple and practical “tool” that I have used for years with great success to get better outcomes in childbirth, to positively impact the local medical community and to promote a human rights agenda. This simple checklist holds providers accountable to high standards in all areas, as it addresses respect, cultural competency, best practices for natural birth and breastfeeding, as well as up-to-date emergency response and skills necessary to mitigate the effects of disease during pregnancy such as HIV/AIDS and malaria. I am referring to the 10 Steps of the International MotherBaby Childbirth Initiative (see sidebar below).

The International MotherBaby Childbirth Initiative (IMBCI) is a tool we in Mercy In Action use to promote human rights in childbirth all over the world. Having the 10 steps makes a much bigger impact than anything just one individual midwife or one small organization like Mercy In Action could achieve. Internationally, it has great weight, as it is based not in any one country but on the results of a survey of birth and breastfeeding organizations in 163 countries and the input of birth experts all over the world who participated in its construction.

[Note: If you are in the US, you would use the Coalition for Improving Maternity Services (CIMS) Mother-Friendly Childbirth Initiative (MFCI). IMBCI originated from the work of the International Committee of CIMS, and the two groups are life-long partners in support of the mission of improved maternity care.]

Midwives, doctors and nurses, indeed entire governments and many NGOs, are working around the world to help ensure that every woman and baby survives birth.

Let me explain why I think IMBCI holds such power to change a seemingly intractable problem.

One of the worst things many midwives and birth workers have faced is going into a country to volunteer and unexpectedly seeing human rights violations, as well as just plain bad practice and sometimes out and out abuse, and feeling helpless to do anything. Cultural competency training and politeness make it feel impossible to “correct” your hosts. The IMBCI steps make it easy; you are not saying they are wrong or you are right; you are not arguing between a doctor or midwife’s way of doing things, and you are not saying any one country’s policies are better than another. With IMBCI, you are simply sharing what the steps are, as determined by people all over the world, and in doing so, you are advocating for human rights and good maternity care practices in a culturally sensitive way.

Some midwives who have run their own clinics and birth centers in other countries, perhaps in response to a natural disaster or refugee situation, have felt at times like their own volunteers were practicing at odds with their values or the tenets of best practice in maternity care. IMBCI makes it easy to bring these things back into alignment and to hold the standard of care for all who are coming in and out as a part of the birth team. Again, it is not “you against them,” but rather the steps have been agreed upon as your facility’s standard and are what every practice decision is measured by.

What about the times when well-intentioned providers seem confused by the question, “Which is more important: safety and good outcomes or a nice gentle birth for the mother?” IMBCI addresses all this and does it brilliantly. The first six steps are all about protecting the birth to keep it natural. The next three steps are about protecting birth by keeping the woman and baby from harm when things are not so natural any more. This is my favorite thing about the steps; they are so balanced and so very practical in real life practice.

The last step is the 10 steps of the Baby Friendly Initiative to protect breastfeeding, which has been proven to be one of the most important things we can do to protect newborn survival.

Here are some ways that Mercy In Action has used the steps in the past decades:

  1. When we go to a new community to start a new birth center, we do not go to the Department of Health or local hospital staff and say, “We are midwives and we want to deliver babies here.” Nor do we say, “We are with Mercy In Action,” a small NGO they have never heard of. Rather we say, “We would like to bring the International MotherBaby Childbirth Initiative 10 Steps to Optimal MotherBaby Maternity Services to this community. May we show you all about it?” Then we roll the slideshow for the local leaders (PowerPoint slides available on the IMBCI website) and we adapt the slides to show local pregnant women. When they hear that WHO, UNICEF, UNFPA, et al. have participated in the creation of the steps, they are always impressed and everyone wants us to show them how to keep the 10 steps, bringing improvements to how women are treated in the entire community. The very first statement in the very first step is about respect, so it is a powerful thing to be able to share this training. Remember, these 10 steps are for doctors or midwives, hospitals or homebirths … they are truly inclusive.
  2. When someone asks us to train local midwives or doctors, or to speak in a hospital, we use the IMBCI 10 Steps in the training. The PowerPoints are easily adaptable to any region of the world and can be as long or as short as the time you have allotted. It is so impactful to be able to say, “This is what has been decided by groups from all over the world,” rather than to say, “You should be doing such and such.” Our trainings have been very well received because they are from a reputable source, the International MotherBaby Childbirth Organization (IMBCO), which was assisted in creating the IMBCI 10 Steps by representatives from WHO, UNICEF, and other recognizable groups, as well as by highly reputable childbirth experts from all over the world.
  3. When heading down into the chaos of the disaster zone, after the world’s largest storm to date hit Southeast Asia in 2013, we literally packed the printed 10 Steps of IMBCI. They were the yardsticks we used regularly to measure how well we were doing in our makeshift birth tents in the middle of intense depravation and suffering. Every day we thought about how we could do better with each of the steps, and we worked toward those goals.
  4. When given a large grant to rebuild by the Center for Disaster Philanthropy and asked to provide capacity building for local midwives after the disaster in the Philippines, we used the IMBCI 10 Steps as our basis for training and created a 40-hour training, taking four hours per step.
  5. In our online courses and live seminars, we use the IMBCI 10 Steps to teach cultural competency; we use it to teach global midwifery skills and we are using it to teach disaster response. It fits easily into any discussion on best practice in midwifery or obstetric care as well. We find we cannot teach a class where we don’t mention it at least once, and often we put in a whole section on it—that is how significant it is to us.
  6. Finally, at this stage in my life, I am often asked to give advice or act as a consultant to others who want to go to Africa, Asia or Latin America and do what Mercy In Action has done so well for over three decades now. I always tell them first how important it is to have a passion for what you do, and then second, I point them to the 10 Steps of IMBCI for the practical framework of how to put together a maternity care project that will work on all levels. If you follow the steps, you will have good outcomes: healthier and happier mothers and babies and a staff that feels validated in their desire to provide the very best care possible. It is a model that works and will work anywhere, because it is adaptable to local situations.

More midwives than ever before are going to volunteer in other countries to bring compassion and humanity to birthing rooms around the world. Many groups, including NARM, are now requiring cultural competency training for midwives, and this is a good thing. But more than attitude adjustments and kindness are necessary going forward. We need a way to measure how well we are doing with both human rights and with saving lives, and the 10 Steps of IMBCI allow us to do that well.

10 Steps of the International MotherBaby Childbirth Initiative
Taken from the IMBCI website:

Step 1—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.

Step 2—Possess and routinely apply midwifery knowledge and skills that enhance and optimize the normal physiology of pregnancy, labor, birth, breastfeeding, and the postpartum period.

Step 3—Inform the mother of the benefits of continuous support during labor and birth, and affirm her right to receive such support from companions of her choice, such as fathers, partners, family members, doulas, or others. Continuous support has been shown to reduce the need for intrapartum analgesia, decrease the rate of operative births and increase mothers’ satisfaction with their birthing experience.

Step 4—Provide drug-free comfort and pain-relief methods during labor, explaining their benefits for facilitating normal birth and avoiding unnecessary harm, and showing women (and their companions) how to use these methods, including touch, holding, massage, laboring in water, and coping/relaxation techniques. Respect women’s preferences and choices.

Step 5—Provide specific evidence-based practices proven to be beneficial in supporting the normal physiology of labor, birth, and the postpartum period, including:

  • Allowing labor to unfold at its own pace, while refraining from interventions based on fixed time limits and utilizing the partogram to keep track of labor progress.
  • Offering the mother unrestricted access to food and drink as she wishes during labor.
  • Supporting her to walk and move about freely and assisting her to assume the positions of her choice, including squatting, sitting, and hands-and-knees, and providing tools supportive of upright positions.
  • Techniques for turning the baby in utero and for vaginal breech delivery.
  • Facilitating immediate and sustained skin-to-skin motherbaby contact for warmth, attachment, breastfeeding initiation, and developmental stimulation, and ensuring that motherbaby stay together.
  • Allowing adequate time for the cord blood to transfer to the baby for the blood volume, oxygen, and nutrients it provides.
  • Ensuring the mother’s full access to her ill or premature infant, including kangaroo care, and supporting the mother to provide her own milk (or other human milk) to her baby when breastfeeding is not possible.

Step 6—Avoid potentially harmful procedures and practices that have no scientific support for routine or frequent use in normal labor and birth. When considered for a specific situation, their use should be supported by best available evidence that the benefits are likely to outweigh the potential harms and should be fully discussed with the mother to ensure her informed consent.

  • shaving
  • enema
  • sweeping of the membranes
  • artificial rupture of membranes
  • medical induction and/or augmentation of labor
  • repetitive vaginal exams
  • withholding food and water
  • keeping the mother in bed
  • intravenous fluids
  • continuous electronic fetal monitoring
  • insertion of a bladder catheter
  • supine or lithotomy position
  • caregiver-directed pushing
  • fundal pressure
  • episiotomy
  • forceps and vacuum extraction
  • manual exploration of the uterus
  • primary and repeat caesarean section
  • suctioning of the newborn
  • immediate cord clamping
  • separation of mother and baby

Step 7—Implement measures that enhance wellness and prevent emergencies, illness, and death of MotherBaby:

  • Provide education about and foster access to good nutrition, clean water, and a clean and safe environment.
  • Provide education in and access to methods of disease prevention, including malaria and HIV/AIDS prevention and treatment, and tetanus toxoid immunization.
  • Provide education in responsible sexuality, family planning, and women’s reproductive rights, and provide access to family planning options.
  • Provide supportive prenatal, intrapartum, postpartum, and newborn care that addresses the physical and emotional health of the motherbaby within the context of family relationships and community environment.

Step 8—Provide access to evidence-based skilled emergency treatment for life-threatening complications. Ensure that all maternal and newborn health care providers have adequate and ongoing training in emergency skills for appropriate and timely treatment of mothers and their newborns.

Step 9—Provide a continuum of collaborative maternal and newborn care with all relevant health care providers, institutions and organizations. Including traditional birth attendants and others who attend births out of hospital in this continuum of care. Specifically, individuals within institutions, agencies and organizations offering maternity-related services should:

  • Collaborate across disciplinary, cultural, and institutional boundaries to provide the motherbaby with the best possible care, recognizing each other’s particular competencies and respecting each other’s points of view.
  • Foster continuity of care during labor and birth for the motherbaby from a small number of caregivers.
  • Provide consultations and transfers of care in a timely manner to appropriate institutions and specialists.
  • Ensure that the mother is aware of and can access available community services specific to her needs and those of her newborn.

Step 10—Strive to achieve the 10 Steps to Successful Breastfeeding as described in the WHO/UNICEF Baby-friendly Hospital Initiative:

  1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
  2. Train all health care staff in skills necessary to implement the policy.
  3. Inform all pregnant women about the benefits and management of breastfeeding.
  4. Help mothers initiate breastfeeding within a half-hour of birth. Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour and encourage mothers to recognize when their babies are ready to breastfeed, offering if needed.
  5. Show mothers how to breastfeed 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 teats 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 the hospital or clinic.

Author’s note: The full text of the International MotherBaby Childbirth Initiative PowerPoint slides on the 10 Steps and translations into several languages are available on the website for you to download and use: imbci.org.

About Author: Vicki Penwell

Vicki Penwell, CPM, is an international humanitarian aid worker, licensed midwife and midwife educator who has practiced since 1981, first in Alaska and then in Asia since 1990. Vicki and her extended family of four generations live and run a birth center in the Philippines, where they founded a nonprofit charitable organization called Mercy In Action, which trains midwives and establishes birth centers in poor countries. The Mercy In Action birth center in Olongapo, Philippines, is run by national midwives and funded by donations so that every delivery is free of charge to the woman and her family. Outcomes of more than 13,500 births have been excellent, using the International MotherBaby Childbirth Initiative (IMBCI) model of maternity care.

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