Family-Centered Maternity Care - ICEA

ICEA Position PaperBy Bonita Katz, IAT, ICCE, ICDFamily-Centered Maternity CarePositionThe International Childbirth EducationAssociation (ICEA) maintains that familycentered maternity care is the foundation onwhich normal physiologic maternity careresides. Further, family-centered maternitycare may be carried out in any birth setting:home, birth center, hospital, or even inemergency situations. In short, familycentered maternity care honors the familyunit by supporting its physical andpsychosocial development with evidencebased, individualized care.IntroductionFamily-centered maternity care (FCMC) has been ahallmark of ICEA since its inception in 1960. At thattime, “family-centered” meant including the father inchildbirth preparation classes and in the birth itself.Over time, even as family members were welcomed inthe birthing room, technology played an increasinglysignificant role in the birth experience. In response tothis, Celeste Phillips wrote the textbook entitled“Family-Centered Maternity Care” (Phillips, 2003) in themid 1970’s. A decade later, McMaster Universitypublished a definition of FCMC that was then adoptedby ICEA (ICEA, n.d.). In 1996, the Coalition for MaternityServices published the Mother Friendly ChildbirthInitiative which was endorsed by many professional andconsumer organizations. (CIMS, 1996) The Public HealthAgency of Canada released its national guidelines forfamily-centered care in 2000 (Health Canada, 2000). Inresponse to the Institute of Medicine’s publication of“Crossing the Quality Chasm”, many professionalorganizations have published statements on “familycentered care” or “patient-centered care” (AWHONN,2012; AAP, 2012). The Royal College of Midwives haspublished position papers on “woman-centred care” (deLabrusse et al, 2015). Its position paper on qualitymidwifery care also establishes benchmarks for womancentered care (RCM, 2014). Most recently theInternational MotherBaby Childbirth Organization hasdeveloped an initiative that describes optimal care forthe mother-baby dyad (IMBCO, n.d.).Definitions of patient-centered care, family-centeredcare, and FCMC differ somewhat between variousdisciplines. In spite of this, there are common themesthese publications share: Birth is a normal, healthy process for most women; Care must be individualized and respectful;

Decision-making should be a collaborative effortbetween the pregnant woman and her healthcareproviders; Education should reflect current, evidence-basedknowledge; Information should be shared freely between thepregnant woman and each of her healthcareproviders; and Mothers and babies should stay together (roomingin).In addition to these common themes, the followingprinciples are endorsed by one or more of theseorganizations: The presence of supportive people during labor andbirth is beneficial to the mother and family; Mothers are the preferred care providers for theirchildren; Freedom of movement is beneficial for the laboringwoman and should be encouraged; Routine interventions that are unsupported byscientific evidence should be avoided; All members of the healthcare team should beeducated about physiologic birth and nonpharmacologic methods of pain management; and Skin-to-skin contact immediately after birth andexclusive breastfeeding should be standards ofpractice.Many organizations have provided a framework ofprotocols for the delivery of healthcare, but what thatcare means to the family is only occasionally alluded to.MacKean (2005) suggests that healthcare providers,acting in the role as experts in their field, have definedthe parents’ role in family-centered care. By doing so,they subtly undermine the desired collaborativerelationship between providers and parents (MacKean,Thurston, & Scott, 2005). As professionals, they havemade a decision for the parents. So the question mustbe asked: what does FCMC mean to the family? What isthe goal of family-centered care as it pertains to thefamilies themselves?Studies that consider patient perception of familycentered care cite common themes that are closelyrelated to those already mentioned: respectful care,informed decision-making, and open communication.Related to these themes, but specifically mentionedfrom the patient’s point of view, was the issue ofemotional support (Rathert, 2012). When describingthe support that women considered most effectiveduring labor, Ferrer et al (2016) listed the woman’sability to express her feelings.RespectMutual respect is foundational to FCMC – respect forpregnancy as a normal, healthy event in a woman’s life,respect for parents as the primary caregivers for theirchildren, respect for each member of the circle of care.Acknowledging pregnancy as a healthy life eventrather than an illness that must be treated willminimize unnecessary interventions. When healthcareproviders reference an illness-based model of care, itinhibits their ability to adopt policies and practices thatsupport pregnancy and birth as physiologically healthylife processes. A positive attitude will convey supportand encouragement to the pregnant woman and herfamily.Parents are the primary caregivers of their children(AAP, 2012; MacKean, et al., 2005). This starts evenbefore birth. Women decide when – and even if – theywill start prenatal care. They choose whether or not tomodify their diet and other aspects of their lifestyle.This autonomy should continue throughout pregnancy,during labor and birth, and through the postpartumperiod.As is mentioned in many of the position paperspreviously cited, respect should extend to each memberof the healthcare team. The goal is to provide qualitycare for mother and baby. This requires the cooperationof all involved – nurse, doula, midwife, physician,lactation consultant, and any others that the womanmay look to for help and advice.

OpennessOpen communication is necessary to provide thehighest quality care. Each member of the circle of careis responsible for their own part in this. The pregnantwoman and her family should be honest about theirdesires and beliefs, communicating clearly and early inthe pregnancy to minimize the risk ofmisunderstandings. Healthcare providers shouldcommunicate just as clearly, not only with the parentsbut with others involved in their care. Collaborationcannot be effective if communication is hindered in anyway.Relational competency is also necessary to FCMC. Thisextends beyond simple communication to includesensitivity and compassion (MacKean, Thurston, &Scott, 2005). Communicating facts without sensitivity isnot characteristic of the openness that definesFCMC.ConfidenceImbuing the woman and her family with confidence iscentral to quality family-centered care. Excellence in thetechnical, medical aspects of care is expected, but notadequate, in and of itself. Birth is more than just themechanical event of moving the baby from the inside tothe outside. It is one of the most significantdevelopmental stages of life – emotionally and socially(Zwelling & Phillips, 2001; Jiminez, Klein, Hivon, &Mason, 2010).A central goal of FCMC is to build the confidence of newparents. Supporting and encouraging new parentsthroughout pregnancy and the postpartum periodbuilds trust in their own abilities (Karl, Beal, O’Hare, &Rissmiller, 2006). When professionals perform tasksparents can do on their own, they undermine theparents’ sense of competence. Care that is truly familycentered supports parents as they care for theirnewborn. In the case of high-risk infants, parents shouldparticipate as much as possible in the infant’s careincluding, but not limited to, the decision-makingprocess, kangaroo care, and breastfeeding.KnowledgeKnowledge is necessaryfor women to be wisedecision-makers. Partof prenatal careshould includeeducating the womanabout pregnancy,birth, and postpartum– making sure she isaware of evidence-basedresearch and all optionsavailable to her. The ICEA Circle of Care is a visualdepiction of the decision-maker and those thatinfluence the decisions she makes.Knowledge is necessary in order for healthcareproviders to provide quality care. Effort must be madeto incorporate evidence-based research into currentpractice. This will not happen if those providing careare not aware of what the research says.DefinitionAs stated in the McMasters University definition, familycentered care is an attitude, not simply a list ofprotocols.In an atmosphere of FCMC, a woman will:1. Choose the caregiver and place of birth that is mostbeneficial for her;2. Work in collaboration with healthcare providers andother advisers that she chooses;3. Have the support people she desires presentwhenever she wishes;4. Move around and use whatever position she feels isbeneficial during labor;

5. Refuse routine procedures that are not evidencebased;6. Practice uninterrupted skin-to-skin contact andbreastfeeding immediately after birth, keeping herbaby with her at all times (rooming in); and7. Have access to a variety of support groups includingthose for breastfeeding, postpartum emotionalhealth, and parenting.Facilities that promote FCMC will provide education fortheir staff that includes information and training incommunication skills, labor support, non-pharmacologicforms of pain relief, breastfeeding support, andperinatal mood disorders. Cultural preferences of themother should be honored. All medical staff shouldsupport the role of the mother as the infant’s primarycare provider.Facilities will also provide evidence-based education forthe mother and her family. In addition to specificclasses for childbirth and breastfeeding, educationshould also be part of each prenatal and postpartumvisit. Information about support groups forbreastfeeding, perinatal mood disorders, and earlychildhood parenting should be readily available.OutcomesFCMC results in greater satisfaction for all involved.Families that are cared for with a family-centered modelwill experience greater satisfaction with their birthexperience. They will have participated in the decisionmaking process which will increase their selfconfidence. They will have validated their learning withreal life experience. Healthcare providers that workwithin a family-centered model will also experiencegreater satisfaction (AAP, 2012).Implications for PracticeFCMC recognizes the significant transitions that occurduring the childbearing year. Physical changes areobvious. Social and emotional adaptations are no lessimportant. Care that is truly family-centered is safe –physically and emotionally. Medical expertise should beaccompanied by compassionate and skillfulcommunication. Collaborative decision-making shouldproceed out of relationships built on mutual respect.Both parents and professionals should have access tothe latest evidence-based research.Many healthcare and governmental agencies haveestablished various protocols to promote familycentered care. These are necessary and helpful. But asICEA has always stated, “FCMC consists of an attituderather than a protocol” (ICEA, n.d.). Attitudes, as wellas organizational structures, must change beforematernity care will be truly family-centered.