Supplement The Journal of Perinatal Education Ò

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1 Winter 2007 Volume 16 Number 1 Supplement The Journal of Perinatal Eucation Ò vancing Normal irth Lamaze Ò International Publication CKGROUND Introuction The Coalition for Improving Maternity Services: Juith. Lothian Methos The Coalition for Improving Maternity Services: Henci Goer 1S 5S Cover photo by Juith Halek THE COLITION FOR IMPROVING MTERNITY SERVICES: EVIDENCE SIS FOR THE TEN STEPS OF MOTHER-FRIENDLY CRE Step 1: Offers ll irthing Mothers Unrestricte ccess to irth Companions, Labor Support, Professional Miwifery Care The Coalition for Improving Maternity Services: Mayri Sagay Leslie an Sharon Storton Step 2: Provies ccurate, Descriptive, Statistical Information bout irth Care Practices The Coalition for Improving Maternity Services Step 3: Provies Culturally Competent Care The Coalition for Improving Maternity Services: Karen Salt Step 4: Provies the irthing Woman With Freeom of Movement to Walk, Move, ssume Positions of Her Choice The Coalition for Improving Maternity Services: Sharon Storton Step 5: Has Clearly Define Policies, Proceures for Collaboration, Consultation, Links to Community Resources The Coalition for Improving Maternity Services: Karen Salt Step 6: Does Not Routinely Employ Practices, Proceures Unsupporte by Scientific Evience The Coalition for Improving Maternity Services: Henci Goer, Mayri Sagay Leslie, an my Romano Step 7: Eucates Staff in Nonrug Methos of Pain Relief an Does Not Promote Use of nalgesic, nesthetic Drugs The Coalition for Improving Maternity Services: Mayri Sagay Leslie, my Romano, an Deborah Woolley Step 8: Encourages ll Mothers, Families to Touch, Hol, reastfee, Care for Their abies The Coalition for Improving Maternity Services: Sharon Storton Step 9: Discourages Nonreligious Circumcision of the Newborn The Coalition for Improving Maternity Services: Karen Salt an my Romano 10S 20S 23S 25S 28S 32S 65S 74S 77S (Continue) i

2 Step 10: Strives to chieve the WHO/UNICEF Ten Steps of the aby-frienly Hospital Initiative to Promote Successful reastfeeing The Coalition for Improving Maternity Services ppenix: irth Can Safely Take Place at Home an in irthing Centers The Coalition for Improving Maternity Services: Mayri Sagay Leslie an my Romano 79S 81S DISCUSSION ND COMMENTRY Discussion The Coalition for Improving Maternity Services: Juith. Lothian Commentary The Coalition for Improving Maternity Services: Susan Hoges, Sanra itonti Stewart, arbara Hotelling, an my Romano 89S 93S ii

3 The Journal of Perinatal Eucation Ò Eitor-in-Chief WenyC.uin,PhD,RN,C,LCCE,FCCE College of Nursing, Seton Hall University ssociate Eitor Juith. Lothian, PhD, RN, LCCE, FCCE College of Nursing, Seton Hall University Columnists/Contributors Deb Gaulin, RN Professional Speaker, Recoring rtist, an uthor arbara.hotelling,sn,cd(don),lcce,fcce Inepenent Chilbirth Eucator an Doula Juith. Lothian, PhD, RN, LCCE, FCCE College of Nursing, Seton Hall University NaynaC.Philipsen,PhD,RN,JD,LCCE,ttorney State of Marylan, Department of Health an Mental Hygiene my M. Romano, MSN, CNM Lamaze Institute for Normal irth TeriShilling,MS,CD(DON),LCCE,FCCE Passion for irth, Lamaze-accreite Chilbirth Eucation Program Managing Eitor Nancy Perry Richmon, V ccess The Journal of Perinatal Eucation Online! Lamaze International Members Go to an view the online journal via the members only page, using your Lamaze International member number to sign in. Libraries Register for free at by selecting the registration link an following the link to institutional registration. Nonmembers or Subscribers Fin out more by visiting the Lamaze International Web site at or by calling The Journal of Perinatal Eucation (ISSN ) is publishe quarterly (winter,spring, summer, fall)at2025mst.nw,suite 800,Washington,DC ; (202) Subscription to the journal is a benefit of membership in Lamaze International. Nonmember print an online subscription prices are $60 for iniviuals an $180 for institutions. ack issues are $25 each. For copyright information, contact Copyright Clearance Center at (978) or [email protected] or The Journal of Perinatal Eucation is peer-reviewe an inexe in Cumulative Inex to Nursing-llie Health Literature (CINHL) an in PubMe Central. Postmaster: Sen aress changes to The Journal of Perinatal Eucation, Lamaze International, 2025 M St. NW, Suite 800, Washington, DC Perioicals postage pai at Washington, DC, an aitional mailing offices. The Journal of Perinatal Eucation Ò is a registere traemark of Lamaze International an part of the Lamaze Communications Ò collection of eucational materials. Lamaze Ò an Lamaze Communications Ò are registere traemarks of Lamaze International, Inc. For more information about Lamaze International membership an Lamaze Chilbirth Eucator Certification, call (202) or tollfree (800) ; [email protected]; or visit the Lamaze International Web site ( For information on Lamaze Parents magazine, call toll-free (800) Eitorial oar nne roussar, CNM, DNS, LCCE, FCCE The University of Louisiana at Lafayette nn Corwin, PhD, LCCE, FCCE Chilbirth Eucator an Parenting Consultant Raymon DeVries, PhD ioethics Program, University of Michigan School of Meicine SusanGennaro,RN,DSN,LCCE,FCCE,FN College of Nursing, New York University Maureen Groer, PhD, RN, FN The University of Tennessee College of Nursing Pamela D. Hill, PhD, RN, FN Maternal Chil Nursing, University of Illinois at Chicago Viola Polomeno, PhD, RN University of Ottawa M. Colleen Stainton, RN, DNSc University of Syney, ustralia Publisher: Lamaze International, Inc M St. NW, Suite 800, Washington, DC ; (800) ; (202) National vertising Representative: Mill River Meia LLC; Steve Kavalgian; 141 oston Post Roa; Ol Lyme, CT 06371; phone (860) ; fax (860) ; [email protected]. Manuscripts shoul be sent to WenyC.uin,PhD,RN,C,LCCE, FCCE, Eitor, via [email protected] orvia postal mail at College of Nursing, Seton Hall University, 400 South Orange venue, South Orange, NJ Phone: (973) uthor Guielines: Prouction an Distribution: Dartmouth Journal Services, Pilgrim Five, Suite 5, 5 Pilgrim Park Roa, Waterbury, VT (802) Lamaze International oar of Directors an visors Presient: Jeannette Crenshaw, RN, ICLC, LCCE, FCCE Presient-Elect: llison Walsh, S, LCCE Past-Presient: Raymon DeVries, PhD Secretary-Treasurer: CarolPenn,DO,M,CD(DON),RYT,LCCE, FCCE oar Members: Debraingham,MS,RN,LCCE;ElenaCarrilloe Reyes, CD (DON), LCCE, FCCE; Juith. Lothian, PhD, RN, LCCE, FCCE;SharonDalrymple,RN,N,ME,LCCE;PamelaSpry,CNM, PhD, LCCE, FCNM Emerita Director: Elisabeth ing, RPT, LCCE, FCCE Eucation Council Chair: Jeanne Green, MT, CD (DON), LCCE, FCCE Certification Council Chair: Wenyuin,PhD,RN,C,LCCE,FCCE Executive Director: Lina L. Harmon, MPH The mission of Lamaze International is to promote, support, an protect normal birth through eucation an avocacy. Our vision is a worl of confient women choosing normal birth. Lamaze International believes that women who are fully informe, confient, an supporte will want normal birth. Lamaze International believes that caregivers shoul respect the birth process an not intervene without compelling meical inication. These evience-base practices aapte from the Worl Health Organization promote, protect, an support normal birth: Labor begins on its own; freeom of movement throughout labor; continuous labor support; no routine interventions; nonsupine (e.g., upright or sie-lying) positions for birth; no separation of mother an baby with unlimite opportunity for breastfeeing. ll articles express the views an opinions of the authors an are not necessarily enorse by Lamaze International. Copyright 2007 by Lamaze International, Inc. ll rights reserve. iii

4 THE COLITION FOR IMPROVING MTERNITY SERVICES: EVIDENCE SIS FOR THE TEN STEPS OF MOTHER-FRIENDLY CRE Introuction The Coalition for Improving Maternity Services: Juith. Lothian, PhD, RN, LCCE, FCCE STRCT The history of the Coalition for Improving Maternity Services as part of a global effort to promote normal birth is escribe. The principles unerlying the Mother-Frienly Chilbirth Initiative are presente, the Ten Steps of Mother-Frienly Care are ientifie, an the evience basis for the Ten Steps is introuce. Journal of Perinatal Eucation, 16(1 Supplement), 1S 4S, oi: / X Keywors: The Coalition for Improving Maternity Services, Mother-Frienly Chilbirth Initiative, Ten Steps of Mother- Frienly Care, normal birth HISTORY OF THE COLITION FOR IMPROVING MTERNITY SERVICES In response to the expaning meicalization of birth an low breastfeeing rates, the 1990s saw a flurry of activity at both international an national levels to normalize birth an increase breastfeeing rates. In 1991, the Worl Health Organization (WHO) an the Unite Nations Chilren s Fun (UNICEF) launche the WHO aby-frienly Hospital Initiative an the Ten Steps to aby-frienly in an effort to ensure that all maternity services, whether freestaning or in a hospital, woul become centers of breastfeeing support. In 1997, the WHO release Care in Normal irth: Practical Guie. parallel process was at work in the Unite States. In 1994, Lamaze International invite sister organizations an stakeholers in the birth an breastfeeing communities to a birth summit in Chicago, Illinois. The goal of that summit was to foster collaboration in a national effort to promote, protect, an support normal birth an breastfeeing. The commitment of that group to work together resulte in the establishment of the Coalition for Improving Maternity Services (CIMS) an, 2 years later, the launch of the Mother-Frienly Chilbirth Initiative an the Ten Steps of the Mother-Frienly Chilbirth Initiative for Mother-Frienly Hospitals, irth Centers, an Home irth Services (Ten Steps of Mother-Frienly Care) (CIMS, 1996). Like the aby-frienly Hospital Initiative, the Mother-Frienly Chilbirth Initiative is intene to help hospitals as well as birthing centers an home birth services provie care that is mother-frienly. The Mother-Frienly Chilbirth Initiative was the first consensus eclaration to eal with labor an birth by a multiisciplinary boy of professional organizations an iniviuals in the history of North merica. Members of CIMS that evelope an ratifie the Mother-Frienly Chilbirth Initiative inclue chilbirth eucators, maternity care nurses, miwives, physicians, oulas, lactation consultants, grassroots avocates for normal birth an breastfeeing, maternity care researchers, university professors, experts in maternal mental health, authors, an parents. The participants met at forums across the Unite States from 1994 to 1996 to ientify the philosophical cornerstones of the Mother- Frienly Chilbirth Initiative an, then, to efine For more information on the Coalition for Improving Maternity Services (CIMS) an copies of the Mother- Frienly Chilbirth Initiative an accompanying Ten Steps of Mother-Frienly Care, log on to the organization s Web site ( or call CIMS toll-free at Introuction Lothian 1S

5 what practices constitute mother-frienly care. t the time of the signing of the Mother-Frienly Chilbirth Initiative, there was representation from 26 organizations (acting on behalf of over 90,000 chilbirth professionals an avocates) an 28 iniviuals (CIMS, 1996). PHILOSOPHICL CORNERSTONES OF THE MOTHER-FRIENDLY CHILDIRTH INITITIVE Normalcy of the irthing Process irth is a normal, natural, healthy process, an women an babies have the inherent wisom necessary for birth. abies are aware, sensitive human beings at birth. reastfeeing provies optimum nourishment for newborns an infants. irth can safely take place in hospitals, birth centers, an homes. The miwifery moel of care, supporting an protecting the normal process of birth, is the most appropriate care for most women uring pregnancy an birth. Empowerment woman s confience an ability to give birth an care for her baby are enhance or iminishe by every person who gives her care an by the environment in which she gives birth. mother an baby are istinct, yet interepenent, uring pregnancy, birth, an infancy. Their interconnecteness is vital an must be respecte. Pregnancy, birth, an the postpartum perio are milestone events in the continuum of life. These experiences profounly affect women, babies, fathers, an families an have important an long-lasting effects on society. utonomy Every woman shoul have the opportunity to have a healthy an joyous birth experience an to give birth as she wishes in an environment in which she feels nurture an secure an in which her emotional well-being, privacy, an personal preferences are respecte. She shoul have access to the full range of options for pregnancy, birth, an nurturing her baby; receive accurate an up-to-ate information about the benefits an risks of all proceures, rugs, an tests; an be allowe the rights of informe consent an informe refusal. Finally, she shoul receive support for making informe choices about what is best for her an her baby base on her iniviual values an beliefs. Do No Harm Interventions shoul not be applie routinely uring pregnancy, birth, or the postpartum perio. If complications arise, meical treatments shoul be base on the latest high-quality evience. Responsibility Each caregiver is responsible for the quality of care she or he provies. Maternity care practices shoul be base not on the nees of the caregiver or provier, but solely on the nees of the mother an chil. Each hospital an birth center is responsible for the perioic review an evaluation, accoring to current scientific evience, of the effectiveness, risks, an rates of use of its meical proceures. Society, through both its government an the public health establishment, is responsible for ensuring access to maternity services for all women an for monitoring the quality of those services. Iniviuals are ultimately responsible for making informe choices about the health-care they an their babies receive. TEN STEPS OF MOTHER-FRIENDLY CRE These principles gave rise to the Ten Steps of Mother-Frienly Care, which support, protect, an promote mother-frienly maternity services. mother-frienly hospital, birth center, or home birth service must fulfill the following steps: 1. Offers all birthing mothers: unrestricte access to the birth companions of her choice, incluing fathers, partners, chilren, family members, an friens; unrestricte access to continuous emotional an physical support from a skille woman for example, a oula or labor-support professional; an access to professional miwifery care. 2. Provies accurate, escriptive, an statistical information to the public about its practices an proceures for birth care, incluing measures of interventions an outcomes. 3. Provies culturally competent care that is, care that is sensitive an responsive to the specific beliefs, values, an customs of the mother s ethnicity an religion. 4. Provies the birthing woman with the freeom to walk, move about, an assume the positions of her choice uring labor an birth (unless restriction is specifically require to correct a complication) an iscourages the use of the lithotomy position. 5. Has clearly efine policies an proceures for: collaborating an consulting throughout the perinatal perio with other maternity services, 2S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

6 incluing communicating with the original caregiver when transfer from one birth site to another is necessary; an linking the mother an baby to appropriate community resources, incluing prenatal an postischarge follow-up an breastfeeing support. 6. Does not routinely employ practices an proceures that are unsupporte by scientific evience, incluing but not limite to the following: shaving, enemas, intravenous rips, withholing nourishment, early rupture of membranes, an electronic fetal monitoring. Other interventions are limite, as follows: has an inuction rate of 10% or less; has an episiotomy rate of 20% or less, with a goal of 5% or less; has a total cesarean rate of 10% or less in community hospitals an 15% or less in tertiary care hospitals; an has a vaginal birth after cesarean rate of 60% or more, with a goal of 75% or more. 7. Eucates staff in nonrug methos of pain relief an oes not promote the use of analgesic or anesthetic rugs not specifically require to correct a complication. 8. Encourages all mothers an families, incluing those with sick or premature newborns or infants who have congenital problems, to touch, hol, breastfee, an care for their babies to the extent compatible with their conitions. 9. Discourages nonreligious circumcision of the newborn. 10. Strives to achieve the WHO/UNICEF Ten Steps of the aby-frienly Hospital Initiative to promote successful breastfeeing. ONGOING RECOGNITION ND EVIDENCE SIS FOR THE TEN STEPS The Mother-Frienly Chilbirth Initiative has receive national an international recognition. n international survey in 2005 provie global support for the Ten Steps of Mother-Frienly Care (Pascali-onaro, 2006). In 2006, authorities of the WHO/UNICEF aby-frienly Hospital Initiative ae an optional component to the baby-frienly assessment tools, which examines mother-frienly care. Each country will etermine whether it will integrate this moule as it upates assessment criteria an tools to the new stanars (WHO, 2003). For the first time, the Worl lliance for reastfeeing ction (2006) has inclue a section on birth practices base on the Mother-Frienly Chilbirth Initiative. In 2006, the international committee of CIMS working with Chilbirth Connection organize a meeting in Geneva. Participants represente 19 national an international organizations, incluing Lamaze International; DON International; the International Confeeration of Miwives; the International Council of Nurses; the International Lactation Consultant ssociation; the caemy of reastfeeing Meicine; the International Peiatric ssociation; the Partnership for Maternal, Newborn an Chil Health; UNICEF; Wellstart International; the Worl lliance for reastfeeing ction; an the Worl Health Organization. The result of this collaboration is an international ocument: the Motheraby International Chilbirth Initiative. This global initiative is expaning the reach of motherfrienly an is soliifying awareness of the impact of birth on breastfeeing (CIMS, in press). In the 10 years since the evelopment of the evience-base Ten Steps of Mother-Frienly Care, birth has become increasingly intervention intensive (Declercq, Sakala, Corry, & pplebaum, 2006). The cesarean rate in the Unite States has risen ramatically an, in 2005, reache an alltime high of 30.2% of births (National Center for Health Statistics, 2006). t the same time, there has been a sharp ecrease in the number of vaginal births after cesarean (Declercq et al., 2006). n increasing boy of research provies support for the value of normal physiologic birth an the angers inherent in interfering in that process (uckley, in press; Enkin et al., 2000). There is a eepening appreciation for the value of evience that examines best possible outcomes rather than just risk an averse outcome (Murphy & Fullerton, 2001). s the crisis in birth escalates, it is critically important to assemble an scrutinize the evience basis for the Ten Steps of Mother-Frienly Care. In this supplementary issue, we present the culmination of our efforts: a systematic review of the evience in support of each of the Ten Steps of Mother-Frienly Care. Members of the CIMS Expert Work Group escribe the methoology use an, then, present the rationales for complying with each step an a systematic review of the evience for each step. ecause the Ten Steps of Mother-Frienly Care is intene to avance mother-frienly care in birth centers an home birth services as well as hospitals, Members of the CIMS Expert Work Group an supporting associates were: Henci Goer,, Project Director Mayri Sagay Leslie, MSN, CNM Juith Lothian, PhD, RN, LCCE, FCCE my Romano, MSN, CNM Karen Salt, CCE, M Katherine Shealy, MPH, ICLC, RLC Sharon Storton, M, CCHT, LMFT Deborah Woolley, PhD, CNM, LCCE Nicette Jukelevics, M, ICCE, CIMS Leaership Team Liaison llana Moore,, Project ssistant Ranall Wallach,, M, Meical Eitor Introuction Lothian 3S

7 we etermine it was important to look carefully at the state of the science relate to birth outsie the hospital. These finings are presente in the ppenix (see pp. 81S 88S). CKNOWLEDGEMENT This project was mae possible by a generous grant from a onor s avise fun of the New Hampshire Charitable Founation. REFERENCES uckley, S. (in press). The physiology of normal birth. New York: Chilbirth Connection. Coalition for Improving Maternity Services. (in press). Motheraby-frienly initiative. Coalition for Improving Maternity Services. (1996). The mother-frienly chilbirth initiative. Retrieve December 9, 2006, from MFCI/steps Declercq, E., Sakala, C., Corry, M., & pplebaum, S. (2006). Listening to mothers II: Report of the secon national U.S. survey of women s chilbearing experiences. New York: Chilbirth Connection. Enkin, M., Keirse, M., Neilson, J., Crowther, C., Duley, L., Honett, E., et al. (2000). guie to effective care in pregnancy an chilbirth (3r e.). New York: Oxfor University Press. Murphy, P.., & Fullerton, J. T. (2001). Measuring outcomes of miwifery care: Development of an instrument to assess optimality. Journal of Miwifery & Women s Health, 46(5), National Center for Health Statistics. (2006). irths: Preliminary ata for Retrieve December 13, 2006, from hestats/prelimbirths05/prelimbirths05.htm Pascali-onaro, D. (2006). Creating a global initiative. Journal of Perinatal Eucation, 15(3), 6 9. Worl lliance for reastfeeing ction. (2006). Health care practices. Retrieve December 9, 2006, from Worl Health Organization. (1997). Care in normal birth: practical guie. Retrieve December 9, 2006, from MSM_96_24 Worl Health Organization. (2003). Implementing the global strategy for infant an young chil feeing (assessment tool); Part 3:53. Geneva, Switzerlan: Worl Health Organization. Worl Health Organization/Unite Nations Chilren s Fun. (1991). aby-frienly hospital initiative. Retrieve December 9, 2006, from programme/breastfeeing/baby.htm JUDITH LOTHIN is a chilbirth eucator in rooklyn, New York, a member of the Lamaze International oar of Directors, an the associate eitor of The Journal of Perinatal Eucation. She is also an associate professor in the College of Nursing at Seton Hall University in South Orange, New Jersey. In honor of Sharron Humenick s commitment to avancing normal birth aroun the worl, Lamaze International establishe the Sharron S. Humenick International Development Fun. Contributions may be sent to Lamaze International, 2025 M Street NW, Suite 800, Washington, DC For more information, visit Lamaze International s Web site ( or call toll-free at (800) Deication to Sharron Humenick Roberta Scaer, MSS efore her untimely eath on September 9, 2006, Sharron Humenick evote her ault life to normal birth an breastfeeing. s a professor of nursing, Lamaze chilbirth eucator, an eitor of The Journal of Perinatal Eucation, Sharron took every opportunity to publicize the intricate, physiological ance between mother an fetus that is normal birth an to publicize how normal birth is most likely to occur when the care provier observes but oes not intervene with rugs, anesthesia, or surgery. Sharron knew if the mother an baby were seen as inseparable from birth an the pair were respecte an treate as a ya, the ance of breastfeeing is most likely to continue after birth. The Mother-Frienly Chilbirth Initiative (MFCI) an the Ten Steps of Mother-Frienly Care that lay out the practical application of the philosophy an principles of the MFCI were conceive an create by the consensus metho over a 2-year perio by several hunre maternity-care professionals, authors, an iniviuals with experience an knowlege of normal birth an breastfeeing. When Sharron first rea the MFCI with its Ten Steps, she knew this historic ocument coul be the catalyst for health professionals to support an protect normal birth an breastfeeing as the stanar of care. She also knew that ocumentation of the research literature supporting the Ten Steps was a critical nee for its use as eviencebase care. Every one of us who ha the privilege of knowing an working with Sharron felt empowere an always encourage to base our work on scientific methoology. She was fearless in publicizing normal birth an breastfeeing as the gol stanar of care for all women. She was equally fearless in emaning that research literature reviews be use to support the creibility of that care. In the last weeks of her life, Sharron wante so much to be part of the team bringing this ocument to fruition. She expresse regret that she was leaving life with so much left to o for normal birth an breastfeeing. We eicate this ocument, Evience asis for the Ten Steps of Mother-Frienly Care, to Sharron Humenick, both to honor her commitment to normal birth an breastfeeing in practice an in proof an to present her commitment as a moel for the reaer. 4S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

8 THE COLITION FOR IMPROVING MTERNITY SERVICES: EVIDENCE SIS FOR THE TEN STEPS OF MOTHER-FRIENDLY CRE Methos The Coalition for Improving Maternity Services: Henci Goer, STRCT In this article, the etails of the methos use to etermine the evience basis of the Ten Steps of Mother- Frienly Care are presente an iscusse. Journal of Perinatal Eucation, 16(1 Supplement), 5S 9S, oi: / X Keywors: systematic review, Ten Steps of Mother-Frienly Care, gency for Healthcare Research an Quality stanars The systematic review is the optimal vehicle for establishing a etaile evience basis for the Ten Steps of Mother-Frienly Care, evelope by the Coalition for Improving Maternity Services (CIMS). Ebell et al. (2004) efine a systematic review as a critical assessment of existing evience that aresses a focuse clinical question, inclues a comprehensive literature search, appraises the quality of stuies, an reports results in a systematic manner (p. 549). This process gives systematic reviews important avantages over the more conventional, narrative review, as escribe (Goer, in press): Systematic reviews cast a wie net. With narrative reviews, no attempt is mae to retrieve all relevant research; instea, reviewers choose what suits their thesis. Systematic reviews escribe their methoology. Narrative reviews make explicit neither how reviewers went about selecting stuies nor the basis on which stuies were inclue or exclue. Systematic reviews apply uniform criteria. Narrative reviewers may inclue or reject a stuy simply because they like or o not like its conclusions. Systematic reviews evaluate quality. Narrative reviews behave as if all stuies are alike, whereas systematic reviews inclue only higher quality stuies. This means that, unlike narrative reviews, systematic reviews raw conclusions from the best evience available. Systematic reviews also clarify where there is insufficient evience to reach a conclusion. Systematic reviews report results in a structure way. Narrative reviews ten to cite specific results from a few stuies in support of a theory. It woul seem at first glance that a vali systematic review woul not be possible given that the Ten Steps of Mother-Frienly Care, the conclusions of the propose review, were alreay fixe. However, when the Ten Steps were evelope, only those steps for which research ha establishe consensus or which were intuitively obvious as best practice were inclue. The task for this project, therefore, was refine to evaluate an present the quality of evience supporting specific rationales for each of the Ten Steps. The review expane on conventional systematic reviews in that it aresse a broa range of For more information on the Coalition for Improving Maternity Services (CIMS) an copies of the Mother- Frienly Chilbirth Initiative an accompanying Ten Steps of Mother-Frienly Care, log on to the organization s Web site ( or call CIMS toll-free at Methos Goer 5S

9 Members of the CIMS Expert Work Group were: Henci Goer,, Project Director Mayri Sagay Leslie, MSN, CNM Juith Lothian, PhD, RN, LCCE, FCCE my Romano, MSN, CNM Karen Salt, CCE, M Katherine Shealy, MPH, ICLC, RLC Sharon Storton, M, CCHT, LMFT Deborah Woolley, PhD, CNM, LCCE outcomes of interest. The content of conventional reviews are generally confine to the presence or absence of short-term, averse, physical outcomes. They also typically evaluate the use of specific interventions in isolation rather than consiering the effects of a high-intervention system of care versus one that is not. Members of the CIMS Expert Work Group (EWG) conucting this review, like the evelopers of the Mother-Frienly Chilbirth Initiative itself, recognize that the absence of isease oes not equal health. They also recognize that the excessive use of intervention is, in itself, harmful because it imposes risks with no evience of benefit. ccoringly, the EWG examine long-term outcomes, psychosocial outcomes, quality of life concerns, the impact of birth practices on breastfeeing, increase nee for further meical intervention, an shortterm morbiity. PROJECT DESIGN The EWG consiste of eight people. Members came from varie professional backgrouns, were committe to mother-frienly care, an were knowlegeable about either maternity care research in general or the research in their specific fiel. EWG members ha expertise in the various aspects of mother-frienly care covering all elements of the Ten Steps of Mother-Frienly Care. The Ten Steps were parcele out among six members of the EWG for research an review (HG, MSL, KS, KS, SS, DW). In accorance with the requirements of systematic reviews, EWG members etermine whether to inclue or exclue stuies base on specific criteria (see later iscussion). They extracte ata from each inclue stuy into a ata summary sheet an liste a reason for each stuy they exclue. The EWG evelope the ata summary template base on guielines publishe by the gency for Healthcare Research an Quality (HRQ) an an article recommening strategies for conucting vali systematic reviews with limite resources (Griffiths, 2002; West et al., 2002). To provie intra- an interobserver reliability, one member of the EWG who i not participate in the primary review process serve as a secon reaer (R). The secon reaer an project irector (HG) etermine which topics woul require a secon reaing. The topics chosen represente the steps (or components thereof) that were consiere most controversial in the literature an/or in practice an inclue the following: home birth, freestaning birth centers, routine intravenous lines, withholing foo an rink in labor, routine early amniotomy, routine electronic fetal monitoring (cariotocography), inuction rate, cesarean-section rate, vaginal birth after cesarean rate, hyrotherapy, epiurals, circumcision, an aoption of babyfrienly status. The secon reaer was then responsible for reaing an inepenently evaluating the quality of the stuies that were reviewe for the preselecte topics an reviewing all ata summary sheets to ensure they were correct an complete. Finally, with no knowlege of the rating assigne by the primary reviewers, the reaer assigne ratings of the strength of the aggregate evience supporting each rationale for the three omains (see later iscussion). ny iscrepancies between the ratings assigne by the primary reviewer an the secon reaer were resolve by consensus. nother EWG member (JL) assume the role of project irector uring the final stages of the process an was involve with writing, eiting, an preparing the ocument for publication. DT SOURCES EWG members conucte searches in the following seven atabases: CINHL, the Cochrane Library, DRE, MEDLINE, OMNI, PsychINFO, an Scirus. In aition, EWG members obtaine stuies from their own files an the reference lists of other stuies an reviews (both narrative an systematic). EWG members inclue stuies publishe between January 1, 1990, an June 1, EXCLUSION CRITERI Stuy exclusions came in two categories: absolute an relative. bsolute exclusions were the following: Stuies publishe in languages other than English. Fortunately, many stuies carrie out in countries where English is not the native language are publishe in English-language journals. Stuies available only as an abstract. Narrative reviews, commentaries, or practice guielines. Narrative reviews an commentaries are opinion pieces. Opinion pieces are the weakest form of evience an were isqualifie on that basis. Practice guielines are generally opinion pieces as well, but even where they are not, unlike systematic reviews, they o not provie the information necessary to evaluate the quality of the literature review on which they are base. Stuies with surrogate outcomes, with two exceptions (see later iscussion). 6S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

10 Grimes an Schulz (2005) efine a surrogate outcome, also calle surrogate marker or intermeiate measure, as an outcome measure that substitutes for a clinical event of true importance (p. 1114). Surrogate outcomes are usually laboratory or imaging stuies thought to be in the causal pathway to a clinical event of interest (p. 1114). For example, a measurement of pelvic-floor muscle strength or an ultrasoun scan showing a efect in the anal sphincter muscle woul be surrogate outcomes as oppose to outcomes measuring urinary or bowel incontinence. Surrogate outcomes often correlate poorly with clinical outcomes, as is the case with the examples cite here. Nonetheless, although surrogate outcomes cannot rule in averse clinical outcomes, they can sometimes be useful in ruling them out. Using the current example, the fact that the pelvic-floor musculature is stronger in women who have spontaneous tears efeats the argument that episiotomy prevents urinary incontinence. The secon situation in which surrogate outcomes can be useful is in cases whereby the enpoint is so rare that it is not feasible to conuct a stuy large enough that is, with sufficient statistical power to have a reasonable chance to etect ifferences between groups. Neonatal eath in fullterm pregnancies with no meical complications serves as one example. In such cases, stuies relying on surrogate outcomes were acceptable, provie the outcome was closely linke to the actual event of interest an coul be measure objectively, as when newborns require prolonge respiratory assistance as oppose to low 5-minute PGR scores. Relative exclusions were left to the iniviual jugment of the EWG member an epene on the specific topic being researche. Relative exclusions were the following: On rare occasions an for reasons liste with the reference, stuies publishe earlier than Stuies in countries lacking meical resources. Weaker stuies (see later iscussion for graing scheme). Stuies inclue systematic reviews. Multiple reports on the same stuy or ataset. Stuies publishe more than 15 years prior to conucting this review or publishe in countries lacking meical resources were exclue to ensure that results coul be generalize to moern meical care. Nonetheless, outcomes of interest might not epen on these factors, an what constitutes a weaker stuy varies from rationale to rationale, epening on what evience is available. Iniviual stuies analyze in systematic reviews were exclue to avoi uplication. Exceptions were mae for the rare case in which the systematic review i not report an outcome of interest, but iniviual stuies inclue in the review i. It shoul be note, however, that systematic reviews often overlappe in the stuies they inclue. s for multiple reports on the same stuy or ataset, only those reports containing unique ata pertinent to the rationales for each of the Ten Steps of Mother- Frienly Care are cite. Finally, the EWG took into account the egree to which protocol was violate in ranomize controlle trials. Ranomize controlle trials are analyze accoring to intent to treat, not actual treatment, because to o otherwise efeats the purpose of ranom assignment. If a few participants receive the treatment of another group, this is not a problem; but in obstetric trials, it is not uncommon for sizeable percentages to be given the treatment of another group. This crossover ecreases the power of the trial to etect ifferences between groups. For example, investigators conucting a ranomize controlle trial of epiural analgesia versus nonepiural pain relief calculate that 263 women per group woul be neee to have an 80% probability of etecting a oubling of the cesarean rate from 7% to 15%, assuming that the noncompliance rates were 25% to 30% in the nonepiural group (Dickinson, Paech, McDonal, & Evans, 2002). The actual noncompliance rate was 60%, which woul require 12,000 participants to etect the same ifference. In some cases, trials an reviews were exclue on this basis; but in others, it was not feasible to o so. Explanatory notes alert the reaer to this caveat, where relevant. GRDING SCHEME Iniviual stuies were given a quality rating using guielines publishe by the HRQ (West et al., 2002). The following selecte elements recommene by HRQ were consiere when evaluating iniviual stuies an, on this basis, each inclue stuy was grae goo, fair, or weak: Systematic Reviews Stuy question: question clearly specifie an appropriate. Search strategy: sufficiently comprehensive an rigorous. Methos Goer 7S

11 Inclusion an exclusion criteria: selection methos specifie an appropriate. Data extraction: rigor an consistency of process, measure of agreement or reproucibility [Note: This only applies to reviews that inclue meta-analyses], extraction of clearly efine interventions/exposures an outcomes for all relevant subjects an subgroups. Stuy quality an valiity: assessment metho specifie an appropriate. Data synthesis an analysis: appropriate use of qualitative an/or quantitative synthesis, with consieration of the robustness of results an heterogeneity issues. Funing or sponsorship: type an sources of support for stuy. Ranomize Controlle Trials Stuy question: clearly focuse an appropriate question. Stuy population: specific inclusion an exclusion criteria. Ranomization: aequate concealment metho use. lining: ouble-blining (e.g., of investigators, caregivers, subjects, assessors, an other key stuy personnel as appropriate) to treatment allocation. Interventions: intervention(s) clearly etaile for all stuy groups. Outcomes: primary an seconary outcome measures specifie; assessment metho stanar, vali, an reliable. Statistical analysis: appropriate analytic techniques that aress stuy withrawals, loss to follow-up, missing ata, an intention to treat; power calculation; assessment of confouning [factors]. Results: measure of effect for outcomes an appropriate measure of precision. Funing or sponsorship: type an sources of support for stuy. Observational Stuies Stuy question: clearly focuse an appropriate question. Stuy population: escription of stuy populations. Comparability of participants: specific inclusion/ exclusion criteria for all groups, criteria applie equally to all groups, comparability of groups at baseline, comparability of follow-up among groups at each assessment, explicit case efinition [case control stuies], controls similar to cases except without conition of interest an with equal opportunity for exposure [case control stuies]. Exposure or intervention: clear efinition of exposure; measurement metho stanar, vali an reliable; exposure measure equally in all stuy groups. Outcome measurement: primary/seconary outcomes clearly efine; outcomes assesse blin to exposure or intervention status; metho of outcome assessment stanar, vali an reliable; length of follow-up aequate for question. Statistical analysis: power calculation provie, assessment of confouning [factors]. Results: measure of effect for outcomes an appropriate measure of precision. Funing or sponsorship: types an sources of support for stuy. lso using HRQ s precepts, the strength of the aggregate evience supporting each rationale was grae,, or C in three omains (West et al., 2002): the aggregate of quality ratings for iniviual stuies. magnitue of effect, numbers of stuies, an sample size or power. the extent to which similar finings are reporte using similar an ifferent stuy esigns. ecause these omains function inepenently of each other, they provie a more nuance evaluation than the usual single-score graing systems. This system also corrects a weakness of systematic reviews. It makes clear, in contrast to systematic review abstracts, cases where only one stuy reports on a particular outcome or where the quantity of evience is small. EWG members varie somewhat in how they presente their ata. s a result, some tables use the term may versus can to inicate rationales for which stuies isagree versus those for which stuies were consistent. itional Graing Information To the HRQ scheme, the EWG ae no evience of benefit an no evience of harm. The concept of no evience of benefit was neee for routine interventions (e.g., routine IV rip) 8S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

12 whereby the quality of research coul not be ascertaine because no research ha examine the policy. In these cases, because benefit has not been establishe but harm has, the policy shoul be abanone until such time as research establishes that benefits outweigh the hazars. The concept of no evience of harm was neee for motherfrienly practices (e.g., freeom of movement uring first-stage labor or the companionship of family an friens) for which research has not establishe benefit other than that women prefer it. Graing schemes frequently use a hierarchy, placing systematic reviews of ranomize trials at the pinnacle followe by iniviual ranomize controlle trials, systematic reviews of observational stuies, iniviual observational stuies, an case reports or series. The Oxfor Centre for Evience- ase Meicine is a well-respecte example of this approach (Centre for Evience-ase Meicine, 2001). However, as Glasziou, Vanenbroucke, an Chalmers (2004) point out, ifferent questions require ifferent stuy types. For example, ranomize controlle trials, even in the aggregate, rarely have the power to etect ifferences in rare, catastrophic outcomes, a category of great importance when exposing healthy women an babies to routine or frequent use of intervention. The EWG, therefore, ecie not to give preceence to any stuy esign, with the exception of systematic reviews. ecause of their nature, systematic reviews potentially offer the strongest evience provie their component stuies are soun because they aggregate evience from multiple stuies. efore incluing a systematic review, EWG members evaluate the component stuies, or at least the larger stuies, if the stuies were too numerous to make it feasible to evaluate them all. When a systematic review was available on a particular topic, EWG members inclue it over stuies of that same topic publishe uring the time perio covere by the review an ae qualifie stuies publishe subsequent to the review. CONCLUSION Developing a systematic review of the Ten Steps of Mother-Frienly Care pose a unique challenge: Meical stuies are esigne to etermine the best ways of preicting, iagnosing, an treating isease. The questions they ask are almost always illness-oriente an take the limite form: Which is better: or? Systematic reviews of meical stuies, therefore, have evolve as a means of evaluating boies of such research. In contrast, this project evaluate a system of care intene to promote health an well-being uring a funamentally normal process. These ifferences necessarily require aapting the conventional techniques use in systematic reviews while ahering to their basic precepts. In this sense, this review is both an extension an reflection of the Mother-Frienly Chilbirth Initiative, which itself expane on conventional strategies for eveloping practice guielines. CIMS hopes that the process that resulte in the Ten Steps of Mother-Frienly Care an the methoology of this systematic review will serve as moels an guielines for others who wish to base maternity care inee, meical care in general on humanistic, holistic, an egalitarian principles while maintaining scientific rigor. REFERENCES Centre for Evience-ase Meicine. (2001). Levels of evience an graes of recommenation. Retrieve December 10, 2006, from of_evience.asp Dickinson, J. E., Paech, M. J., McDonal, S. J., & Evans, S. F. (2002). The impact of intrapartum analgesia on labour an elivery outcomes in nulliparous women. The ustralian an New Zealan Journal of Obstetrics an Gynaecology, 42(1), Ebell, M. H., Siwek, J., Weiss,. D., Woolf, S. H., Susman, J., Ewigman,., et al. (2004). Strength of recommenation taxonomy (SORT): patient-centere approach to graing evience in the meical literature. merican Family Physician, 69(3), Glasziou, P., Vanenbroucke, J. P., & Chalmers, I. (2004). ssessing the quality of research. MJ, 328(7430), Goer, H. (in press). Obstetric myths versus research realities (2n e.). nn rbor, MI: University of Michigan Press. Griffiths, P. (2002). Evience informing practice: Introucing the mini-review. ritish Journal of Community Nursing, 7(1), Grimes, D.., & Schulz, K. F. (2005). Surrogate en points in clinical research: Hazarous to your health. Obstetrics & Gynecology, 105(5), West, S., King, V., Carey, T. S., Lohr, K. N., McKoy, N., Sutton, S. F., et al. (2002). Systems to rate the strength of scientific evience (No. HRQ Publication 02-E016). Rockville, MD: gency for Healthcare Research an Quality. HENCI GOER is an awar-winning meical writer, author of The Thinking Woman s Guie to a etter irth an Obstetric Myths an Research Realities, an an internationally known speaker. n inepenent scholar, Goer is an acknowlege expert on evience-base maternity care. She is currently a resient expert for the Lamaze Institute for Normal irth an moerates the online Normal irth Forum ( Methos Goer 9S

13 THE COLITION FOR IMPROVING MTERNITY SERVICES: EVIDENCE SIS FOR THE TEN STEPS OF MOTHER-FRIENDLY CRE Step 1: Offers ll irthing Mothers Unrestricte ccess to irth Companions, Labor Support, Professional Miwifery Care The Coalition for Improving Maternity Services: Mayri Sagay Leslie, MSN, CNM Sharon Storton, M, CCHT, LMFT STRCT The first step of the Ten Steps of Mother-Frienly Care insures that women have access to a wie variety of support in labor an uring the pregnancy an postpartum perios: unrestricte access to birth companions of their choice, incluing family an friens; unrestricte access to continuous emotional an physical support from a skille woman such as a oula; an access to miwifery care. The rationales for the importance of each factor an the evience to support those rationales are presente. Journal of Perinatal Eucation, 16(1 Supplement), 10S 19S, oi: / X Keywors: labor support, oula, miwifery care, nurse-miwives, chilbirth satisfaction, maternal satisfaction Step 1: Offers all birthing mothers: For a escription an iscussion of the methos use to etermine the evience basis of the Ten Steps of Mother-Frienly Care, see this issue s Methos article by Henci Goer on pages 5S 9S. unrestricte access to the birth companions of her choice, incluing fathers, partners, chilren, family members, an friens; unrestricte access to continuous emotional an physical support from a skille woman for example, a oula or labor-support professional; an access to professional miwifery care. Step 1: Offers all birthing mothers: unrestricte access to the birth companions of her choice, incluing fathers, partners, chilren, family members, an friens. In the past, when birth typically took place in homes, truste family an friens provie care an support for the laboring woman. This support continues to be value by women an is associate with increase satisfaction with chilbirth. 10S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

14 ccess to irth Companions Evience Grae No evience of meical harm foun for: unrestricte access by mother to birth companions access of mother to companions of her choice fathers at birth partners at birth chilren at birth family members at birth friens at birth Mothers reporte less satisfaction with birth support when the support provier was a nurse or a octor compare with a partner or oula (traine or experience woman who provies continuous labor support) (DeClercq, 2002). NEH N* The perception of support uring labor is a key ingreient in a woman s ultimate satisfaction with her birth experience (Honett, 2002). ** The perception of support uring labor is more important in etermining a woman s satisfaction with her birth experience than her experience of pain or her satisfaction with methos of pain relief (Honett, 2002). ¼ goo, ¼ fair, N ¼ not applicable, NEH ¼ no evience of harm Quality ¼ aggregate of quality ratings for iniviual stuies Quantity ¼ magnitue of effect, numbers of stuies, an sample size or power Consistency ¼ the extent to which similar finings are reporte using similar an ifferent stuy esigns *only one stuy **multiple stuies in systematic review (SR) ** For more information on the Coalition for Improving Maternity Services (CIMS) an copies of the Mother- Frienly Chilbirth Initiative an accompanying Ten Steps of Mother-Frienly Care, log on to the organization s Web site ( or call CIMS toll-free at INCLUDED STUDIES DeClercq, E., Sakala, C., Corry, M., pplebaum, S., & Risher, P. (2002). Listening to mothers: Report of the first national U.S. survey of women s chilbearing experiences. New York: Maternity Center ssociation. Honett, E. (2002). Pain an women s satisfaction with the experience of chilbirth: systematic review. merican Journal of Obstetrics & Gynecology, 186, EXCLUDED STUDIES ryce, R. (1991). Support in pregnancy. International Journal of Technology ssessment in Health Care, 7(4), Reason: Not applicable. Data inclues prenatal perio only. Campero,L.,Garcia,C.,Diaz,C.,Ortiz,O.,Reynoso, S., & Langer,. (1998). lone I wouln t have known what to o: qualitative stuy on social support uring labor an elivery in Mexico. Social Science & Meicine, 47(3), Reason: Not applicable. Does not iscuss unrestricte access to companion of mother s choice. Companion was assigne oula. Honett,E.,Gates,S.,Hofmeyr,G.,&Sakala,C.(2003). Continuous support for women uring chilbirth. The Cochrane Database of Systematic Reviews, (3). rt. No. CD DOI: / Reason: Not applicable. Does not inclue unrestricte access to companion of mother s choice. Companions were assigne hospital staff, meical professionals, or oulas. Hofmeyr, G., Nikoem, V., Wolman, W., Chalmers,., & Kramer, T. (1991). Companionship to moify the clinical birth environment: Effects on progress an perceptions of labor an breastfeeing. ritish Journal of Obstetrics & Gynaecology, 98, Reason: Not applicable. Does not iscuss unrestricte access to companion of mother s choice. Companion was assigne oula. Klaus, M., Kennell, J., Robertson, S., & Sosa, R. (1986). Effects of social support uring parturition on maternal an infant morbiity. ritish Meical Journal (Clinical Research E.), 293(6547), Reason: Not applicable. Does not iscuss unrestricte access to companion of mother s choice. Companion was assigne oula. Mai,., Sanall, J., ennett, R., & Macleo, C. (1999). Effects of female relative support in labor: ranomize controlle trial. irth, 26(1), 4 8. Reason: Not applicable. Female relatives in this frican culture ha experience supporting women in labor an, therefore, functione as oulas. Wolman, W., Chalmers,., Hofmeyr, G., & Nikoem, V. C. (1993). Postpartum epression an companionship in the clinical birth environment: ranomize, controlle stuy. merican Journal of Obstetrics & Gynecology, 168, Reason: Not applicable. Does not iscuss unrestricte access to companion of mother s choice. Companion was an assigne oula. Members of the CIMS Expert Work Group were: Henci Goer,, Project Director Mayri Sagay Leslie, MSN, CNM Juith Lothian, PhD, RN, LCCE, FCCE my Romano, MSN, CNM Karen Salt, CCE, M Katherine Shealy, MPH, ICLC, RLC Sharon Storton, M, CCHT, LMFT Deborah Woolley, PhD, CNM, LCCE Step 1: ccess Leslie & Storton 11S

15 Step 1: Offers all birthing mothers: unrestricte access to continuous emotional an physical support from a skille woman for example, a oula, or labor-support professional. cross time an cultures, women have been supporte uring labor by other women who are skille in proviing continuous emotional an physical support. When chilbirth move to the hospital, this component of supportive care was largely lost. Skille support (ifferentiate from support provie by family an friens or nursing an meical support) is once again available to women an has been stuie extensively over the last ecae. ccess to Labor Support No evience of harm foun for unrestricte access to continuous emotional an physical support from a skille woman (Honett, 2003). Compare with a similar population receiving comparable clinical care, continuous labor support by a skille or experience woman reuces the likelihoo of having pain meication in labor, increases the likelihoo of spontaneous birth (vaginal birth without the ai of vacuum extraction or forceps), increases satisfaction with the birth experience, an reuces the likelihoo of severe postpartum pain (Honett, 2003; Schroeer, 2005; Simkin, 2002; Walenström, 2004). Compare with a similar population receiving comparable clinical care, continuous labor support by a skille or experience woman results in fewer newborn amissions to a neonatal intensive care unit (Honett, 2003). Compare with outcomes from stuies of labor support provie by nurses (hospital employees), stuies where support was provie by a nonmeical traine or experience woman resulte in fewer cesareans, less nee for oxytocin uring labor, an less nee for pain meication (Honett, 2003; Simkin, 2002; Simkin, 2004). ¼ goo Quality ¼ aggregate of quality ratings for iniviual stuies Quantity ¼ magnitue of effect, numbers of stuies, an sample size or power Consistency ¼ the extent to which similar finings are reporte using similar an ifferent stuy esigns *no stuy reporte harm **multiple stuies in SR Evience Grae * an ** ** INCLUDED STUDIES Honett, E., Gates, S., Hofmeyr, G., & Sakala, C. (2003). Continuous support for women uring chilbirth. The Cochrane Database of Systematic Reviews (3). rt. No.: CD Schroeer, C., & ell, J. (2005). Doula birth support for incarcerate pregnant women. Public Health Nursing, 22(1), Simkin, P., & oling,. (2004). Upate on nonpharmacologic approaches to relieve labor pain an prevent suffering. Journal of Miwifery & Women s Health, 49(6), Simkin, P. P., & O Hara, M. (2002). Nonpharmacologic relief of pain uring labor: SRs of five methos. merican Journal of Obstetrics & Gynecology, 186(5 Suppl Nature), S Walenström, U., Hilingsson, I., Rubertsson, C., & Raesta, I. (2004). negative birth experience: Prevalence an risk factors in a national sample. irth, 31(1), EXCLUDED STUDIES Lantz, P. M., Low, L. K., Varkey, S., & Watson, R. L. (2005). Doulas as chilbirth paraprofessionals: Results from a national survey. Women s Health Issues, 15(3), Reason: Not relevant. Survey of emographic characteristics of oulas, not their impact on birth outcomes. Meltzer,. (2004). Pai labor: Labor support oulas an the institutional control of birth. Unpublishe issertation, University of Pennsylvania. Reason: Not relevant. Stuy a iscussion of oulas as a wage-earning population, not their impact on birth outcomes. 12S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

16 Step 1: Offers all birthing mothers: access to professional miwifery care. ccess to professional miwifery care is an important component of the Ten Steps of Mother-Frienly Care base on the following principles: utonomy In orer to choose what best suits their nees, circumstances, an preferences, women must have access to all types of practitioners who are qualifie to take sole responsibility for the care of chilbearing women uring the prenatal, intrapartum, an postpartum perios. Moel of care While any iniviual practitioner may practice a moel of care conforming with the Ten Steps of Mother-Frienly Care, research shows that such practitioners are more likely to be miwives. For the purposes of this ocument, professional miwifery is efine as a skille attenant who has achieve official recognition as a miwife through licensure, registration, or certification. ccess to professional miwifery care is efine as access to a professional miwife who is authorize to provie care inepenently throughout the chilbearing perio to women who are at low or moerate risk of complications. Professional miwives may atten births within hospitals, freestaning birth centers, the family s home, or some combination of these locations. This review oes not specifically aress stuies pertaining to location for birth. (See the ppenix on pages 81S 88S for a review of birth locations.) However, because miwives ten to provie most of the care in out-of-hospital settings, stuies of care in out-of-hospital settings are inclue here if miwives were the sole proviers of care in that setting. ccess to Miwifery Care Compare with physicians caring for similar populations, care by professional miwives results in the following maternal outcomes: more antepartum visits an/or increase length of visits (De Koninck, 2001; Fraser, 2000). more eucation an counseling uring prenatal care (e.g., nutrition, sexuality, smoking) (Oakley, 1996). ecrease incience of antepartum an/or intrapartum hypertension (PIH, PET, preeclampsia) (lanchette, 1995; Tucker, 1996; Turnbull, 1996). fewer hospital amissions uring the antepartum perio (Fraser, 2000; Jackson, 2003 merican Journal of Public Health (JPH); Honett, 2000; Tucker, 1996). fewer inuctions of labor (see also Step 6, p. 42S) (lanchette, 1995; Campbell, 1999; Davis,1994; Fraser, 2000; Harvey, 1996; Jackson, 2003 JPH; Johnson, 2005; Tucker, 1996; Turnbull, 1996; Woocock, 1994). Evience Grae C N* (One stuy foun equivalent rates of hypertension with miwifery care.) (One stuy foun equivalent rates of hospital amissions with miwifery care.) (One stuy foun equivalent inuction rates with miwifery care.) (Continue ) Step 1: ccess Leslie & Storton 13S

17 (Continue) ccess to Miwifery Care less nee for augmentation of labor (lanchette, 1995; oner-ler, 2004; Campbell, 1999; Davis, 1994; Fraser, 2000; Harvey, 1996; Hueston, 1993; Jackson, 2003 JPH; Johnson, 2005; Law, 1999; Tucker, 1996). increase access to foo an rink in labor (Jackson, 2003 JPH; Oakley, 1995). increase use of ambulation in labor (see also Step 4, p. 25S) (Jackson, 2003 JPH; Hunley, 1994; Oakley, 1995). less use of nonsupine positions for birth (see also Step 4, p. 26S) (oner-ler, 2004; De Koninck, 2001; Oakley, 1995). less use of intravenous fluis in labor (see also Step 6, p. 34S) (Harvey, 1996; Jackson, 2003 JPH; Johnson, 2005; Law, 1999; Oakley, 1995). less use of amniotomy in labor (see also Step 6, p. 38S) (Fraser, 2000; Harvey, 1996; Jackson, 2003 JPH; Johnson, 2005). fewer episoes of abnormal fetal heart rate in labor (Jackson, 2003 JPH; Woocock, 1994). less use of continuous electronic fetal monitoring, external an internal (see also Step 6, p. 39S) (Fraser, 2000; Jackson, 2003 JPH; Johnson, 2005; Hunley, 1994; Oakley, 1995). more effective pain management in labor, incluing: Evience Grae s no nee for pain meications (Turnbull, 1996). N* s less nee for analgesia (Jackson, 2003 JPH; Harvey, 1996; Honett, 2000; Law, 1999; Oakley, 1995; Turnbull, 1996). s less nee for epiural anesthesia (lanchette, 1995; Campbell, 1999; Carr, 2000; Davis, 1994; Fraser, 2000; Jackson, 2003 JPH; Harvey, 1996; Honett, 2000; Hunley, 1994; Oakley, 1995; Turnbull, 1996). s more use of nonpharmacological pain relief measures, incluing hyrotherapy, comfort measures, an other strategies (see also Step 7, p. 65S) (Campbell, 1999; Fraser, 2000; Harvey, 1996; Hunley, 1994; Jackson, 2003 JPH; Oakley, 1995). (Two stuies foun equivalent rates of labor augmentation rates with miwifery care.) (Two stuies foun equivalent rates of analgesia use in labor with miwifery care.) (Two stuies foun equivalent epiural rates with miwifery care.) (Continue ) 14S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

18 (Continue) ccess to Miwifery Care increase or equivalent number of spontaneous vaginal births (Harvey, 1996; Jackson, 2003 JPH; Law, 1999; Tucker, 1996; Walsh, 2004). fewer or equivalent vaginal instrumental births (vacuum extraction an forceps) (Davis, 1994; Duran, 1992; Fraser, 2000; Harvey, 1996; Jackson, 2003 JPH; Johnson, 2005; Law, 1999; Oakley, 1995; Woocock, 1994). fewer cesarean sections, as follows: fewer cesareans overall (Davis, 1994; Duran, 1992; Fraser, 2000; Harvey, 1996; Hueston, 1993; Jackson, 2003 JPH; Johnson, 2005; Law, 1999; Walsh, 2004). s s fewer cesareans in nulliparous women (Davis, 1994; Fraser, 2000). s fewer cesareans in multiparous women (Davis, 1994; Fraser, 2000). s s s s more vaginal births after cesarean (VCs) (lanchette, 1995). fewer cesareans for emergencies in labor, such as fetal istress (Davis, 1994; Tucker, 1996; Woocock, 1994). fewer cesareans for inaequate progress in labor (Davis, 1994). fewer first cesareans (lanchette, 1995; Davis, 1994; Fraser, 2000; Jackson, 2003 JOGGN). fewer perineal injuries, as measure by: s fewer episiotomies (lanchette, 1995; oner-ler, 2004; Campbell, 1999; Fraser, 2000; Harvey, 1996; Harvey, 2002; Hueston, 1993; Hunley, 1994; Jackson, 2003 JPH; Johnson, 2005; Law, 1999; Oakley, 1995; Turnbull, 1996; Walsh, 2004). s s fewer 3r- an 4th-egree lacerations (Fraser, 2000; Oakley, 1996; Woocock, 1994). more intact perineums (oner-ler, 2004; Campbell, 1999; Turnbull, 1996). Evience Grae (One stuy foun equivalent cesarean section rates with miwifery care.) C N* (One stuy foun equivalent rates of cesarean sections for emergencies with miwifery care.) N* (One stuy foun equivalent rates of 3r- an 4th-egree tears with miwifery care.) (Continue ) Step 1: ccess Leslie & Storton 15S

19 (Continue) ccess to Miwifery Care lower or equivalent incience of shouler ystocia (lanchette, 1995; Woocock, 1994). Evience Grae lower incience of retaine placenta (Woocock, 1994). N* fewer or equivalent postpartum hemorrhages (lanchette, 1995; oner-ler, 2004; Fraser, 2000; Law, 1999; Oakley, 1996; Turnbull, 1996; Woocock, 1994). lower or comparable incience of maternal infection or nee for antibiotics after birth (lanchette, 1995; Fraser, 2000; Jackson, 2003 JPH; Oakley, 1996). Compare with physicians caring for similar populations, care by professional miwives results in the following perinatal outcomes: more infants exclusively breastfeeing at birth (De Koninck, 2001; Oakley, 1996). more infants exclusively breastfeeing 2 4 months after birth (De Koninck, 2001). more infants remaining with the mother throughout hospital stay (Oakley, 1996). fewer or equivalent number of preterm births (Fraser, 2000; Jackson, 2003 JPH; Tucker, 1996; Turnbull, 1996; Woocock, 1994). fewer or equivalent number of low-birthweight infants (lanchette, 1995; Davis, 1994; Fraser, 2000; Hueston, 1993; Jackson, 2003 JPH; MacDorman, 1998; Turnbull, 1996; Woocock, 1994). C (One stuy foun an increase in postpartum hemorrhages with miwifery care in ustralia.) N* N* lower incience of fetal istress (Jackson, 2003 JPH). C N* lower or equivalent incience of infant aciemia when compare with physician care (oner-ler, 2004; Davis, 1994). fewer infants requiring resuscitation at birth (Honett, 2000; Woocock, 1994). fewer infants with birth trauma (Woocock, 1994). N* C (Continue ) 16S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

20 (Continue) ccess to Miwifery Care fewer or equivalent number of infants amitte to intensive care units after birth (Harvey, 1996; Jackson, 2003 JPH; Law, 1999; Tucker, 1996; Turnbull, 1996). fewer infant sepsis workups for infection that requires treatment (Jackson, 2003 JPH). similar incience of neonatal reamission (Jackson, 2003 JPH). fewer or comparable number of perinatal eaths (Duran, 1992; Johnson, 2005; MacDorman, 1998; Tucker, 1996; Woocock, 1994). Care by professional miwives oes not increase the incience of averse outcomes in women with risk factors such as poor access to care, low economic status, late entry to care, poor nutrition, substance abuse, an moerate to high meical risk factors. Instea, it results in fewer cesarean sections, fewer vaginal instrumental births, an more VCs (lanchette, 1995; Davison, 2002; Mahoney, 2005). Women care for by professional miwives report increase satisfaction in the following areas (De Koninck, 2001; Harvey, 2002; Honett, 2000; Hunley, 1997; Oakley, 1995; Shiels, 1998; Turnbull, 1996): relationship with their care provier (continuity of care, empathy, an the overall course of care) access to information an counseling quality of birth experience (feeling well prepare, feeling supporte, enjoying the experience, participating in ecisions, feeling care is personalize) Professional miwifery care reuces costs when compare with physicians working with similar populations for the following reasons (lanchette, 1995; Carr, 2000; Fraser, 2000; Harvey, 1996; Oakley, 1995; Oakley, 1996; Turnbull, 1996): miwives use fewer antepartum an intrapartum tests an proceures women uner the care of miwives experience fewer preterm births, fewer cesarean sections, an fewer vaginal instrumental births; thus, an attenant reuces incience of the complications they may cause) women uner the care of miwives experience shorter postpartum stays women uner the care of miwives experience fewer hospital reamissions Evience Grae C N* N* (One stuy foun equivalent rates of hospital stays an reamission rates with miwifery care.) ¼ goo, ¼ fair, N ¼ not applicable, PIH ¼ pregnancy-inuce hypertension, PET ¼ preeclampsia toxemia, VC ¼ vaginal birth after cesarean Quality ¼ aggregate of quality ratings for iniviual stuies Quantity ¼ magnitue of effect, numbers of stuies, an sample size or power Consistency ¼ the extent to which similar finings are reporte using similar an ifferent stuy esigns *only one stuy Step 1: ccess Leslie & Storton 17S

21 INCLUDED STUDIES lanchette, H. (1995). Comparison of obstetric outcome of a primary-care access clinic staffe by certifie nurse-miwives an a private practice group of obstetricians in the same community. merican Journal of Obstetrics & Gynecology, 172(6), ; iscussion oner-ler,., oner, K., Kimberger, O., Lozanov, P., Husslein, P., & Mayerhofer, K. (2004). Influence of the birth attenant on maternal an neonatal outcomes uring normal vaginal elivery: comparison between miwife an physician management. Wiener Klinische Wochenschrift, 116(11 12), Campbell, R., Macfarlane,., Hempsall, V., & Hatchar, K. (1999). Evaluation of miwife-le care provie at the Royal ournemouth Hospital. Miwifery, 15(3), Carr, C.. (2000). Charges for maternity services: ssociations with provier type an payer source in a university teaching hospital. Journal of Miwifery & Women s Health, 45(5), Davison, M. R. (2002). Outcomes of high-risk women care for by certifie nurse-miwives. Journal of Miwifery & Women s Health, 47(1), Davis, L. G., Riemann, G. L., Sapiro, M., Minogue, J. P., & Kazer, R. R. (1994). Cesarean section rates in lowrisk private patients manage by certifie nursemiwives an obstetricians. Journal of Nurse-Miwifery, 39(2), De Koninck, M., lais, R., Joubert, P., & Gagnon, C. (2001). Comparing women s assessment of miwifery an meical care in Quebec, Canaa. Journal of Miwifery & Women s Health, 46(2), Duran,. M. (1992). The safety of home birth: The farm stuy. merican Journal of Public Health, 82(3), Fraser, W., Hatem-smar, M., Krauss, I., Maillar, F., reart, G., & lais, R. (2000). Comparison of miwifery care to meical care in hospitals in the Quebec pilot projects stuy: Clinical inicators. L Equipe Evaluation es Projets-Pilotes Sages-Femmes. Canaian Journal of Public Health, 91(1), Harvey, S., Jarrell, J., rant, R., Stainton, C., & Rach, D. (1996). ranomize, controlle trial of nursemiwifery care. irth, 23(3), Harvey, S., Rach, D., Stainton, M. C., Jarrell, J., & rant, R. (2002). Evaluation of satisfaction with miwifery care. Miwifery, 18(4), Honett, E. D. (2000). Continuity of caregivers for care uring pregnancy an chilbirth. Cochrane Database of Systematic Reviews, (2), CD Hueston, W. J., & Ruy, M. (1993). comparison of labor an elivery management between nurse miwives an family physicians. The Journal of Family Practice, 37(5), Hunley, V.., Cruickshank, F. M., Lang, G. D., Glazener, C. M., Milne, J. M., Turner, M., et al. (1994) Miwife manage elivery unit: ranomise controlle comparison with consultant le care. MJ, 309(6966), Hunley, V.., Milne, J. M., Glazener, C. M., & Mollison, J. (1997). Satisfaction an the three C s: Continuity, choice an control. Women s views from a ranomise controlle trial of miwife-le care. ritish Journal of Obstetrics & Gynaecology, 104(11), Jackson,D.J.,Lang,J.M.,Ecker,J.,Swartz,W.H.,& Heeren, T. (2003). Impact of collaborative management an early amission in labor on metho of elivery. Journal of Obstetric, Gynecologic, an Neonatal Nursing, 32(2), , iscussion Jackson, D. J., Lang, J. M., Swartz, W. H., Ganiats, T. G., Fullerton, J., Ecker, J., et al. (2003). Outcomes, safety, an resource utilization in a collaborative care birth center program compare with traitional physicianbase perinatal care. merican Journal of Public Health, 93(6), Johnson, K. C., & Daviss,.. (2005). Outcomes of planne home births with certifie professional miwives: Large prospective stuy in North merica. MJ, 330(7505), Law, Y. Y., & Lam, K. Y. (1999). ranomize controlle trial comparing miwife-manage care an obstetricianmanage care for women assesse to be at low risk in the initial intrapartum perio. Journal of Obstetrics an Gynaecology Research, 25(2), MacDorman, M. F., & Singh, G. K. (1998). Miwifery care, social an meical risk factors, an birth outcomes in the US. Journal of Epiemiology an Community Health, 52(5), Mahoney, S. F., & Malcoe, L. H. (2005). Cesarean elivery in Native merican women: re low rates explaine by practices common to the Inian health service? irth, 32(3), Oakley, D., Murray, M. E., Murtlan, T., Hayashi, R., nersen, H. F., Mayes, F., et al. (1996). Comparisons of outcomes of maternity care by obstetricians an certifie nurse-miwives. Obstetrics an Gynecology, 88(5), Oakley, D., Murtlan, T., Mayes, F., Hayashi, R., Petersen,.., Rorie, C., et al. (1995). Processes of care. Comparisons of certifie nurse-miwives an obstetricians. Journal of Nurse-Miwifery, 40(5), Shiels, N., Turnbull, D., Rei, M., Holmes,., McGinley, M., & Smith, L. N. (1998). Satisfaction with miwifemanage care in ifferent time perios: ranomise controlle trial of 1299 women. Miwifery, 14(2), Tucker, J. S., Hall, M. H., Howie, P. W., Rei, M. E., arbour, R. S., Florey, C., et al. (1996). Shoul obstetricians see women with normal pregnancies? multicentre ranomise controlle trial of routine antenatal care by general practitioners an miwives compare with share care le by obstetricians. MJ, 312(7030), Turnbull, D., Holmes,., Shiels, N., Cheyne, H., Twale, S., Gilmour, W. H., et al. (1996). Ranomise, controlle trial of efficacy of miwife-manage care. Lancet, 348(9022), S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

22 Walsh, D., & Downe, S. M. (2004). Outcomes of freestaning, miwife-le birth centers: structure review. irth, 31(3), Woocock, H. C., Rea,. W., ower, C., Stanley, F. J., & Moore, D. J. (1994). matche cohort stuy of planne home an hospital births in Western ustralia Miwifery, 10(3), EXCLUDED STUDIES nerson, R. E., & Murphy, P.. (1995). Outcomes of 11,788 planne home births attene by certifie nurse-miwives. retrospective escriptive stuy. Journal of Nurse-Miwifery, 40(6), Reason: Have better quality, more recent research; no comparative ata inclue. Caelli, K., Downie, J., & Letenre,. (2002). Parents experiences of miwife-manage care following the loss of a baby in a previous pregnancy. Journal of vance Nursing, 39(2), Reason: Not relevant. Evaluation is of a program, not professional miwifery care. Greulich,., Paine, L. L., McClain, C., arger, M. K., Ewars, N., & Paul, R. (1994). Twelve years an more than 30,000 nurse-miwife-attene births: The Los ngeles County 1 University of Southern California women s hospital birth center experience. Journal of Nurse-Miwifery, 39(4), Reason: Not applicable. Stuy lacks comparative analysis with physician outcomes. Homer, C. S., Davis, G. K., roie, P. M., Sheehan,., arclay, L. M., Wills, J., et al. (2001). Collaboration in maternity care: ranomise controlle trial comparing community-base continuity of care with stanar hospital care. ritish Journal of Obstetrics an Gynaecology, 108(1), Compare miwifery care to share care, which inclue obstetricians, general practitioners, an miwives. However, only 34% of the stuy group participants actually ha miwifery care throughout. Stuy oes not provie ata on time of transfers; hence, as much as 66% of the intrapartum an postpartum ata on miwifery care may be from physician-manage care. Hunley, V.., Cruickshank, F. M., Milne, J. M., Glazener, C. M., Lang, G. D., Turner, M., et al. (1995). Satisfaction an continuity of care: Staff views of care in a miwife-manage elivery unit. Miwifery, 11(4), Stuy lacke significants ata for accurate comparison incluing costs associate with aitional use of interventions, longer length of stay, an epiurals ocumente in control arm of trial. Hunley, V.., Donalson, C., Lang, G. D., Cruickshank, F. M., Glazener, C. M., Milne, J. M., et al. (1995). Costs of intrapartum care in a miwife-manage elivery unit an a consultant-le labour war. Miwifery, 11(3), Reason: Not relevant. Janssen, P.., Lee, S. K., Ryan, E. M., Etches, D. J., Farquharson, D. F., Peacock, D., et al. (2002). Outcomes of planne home births versus planne hospital births after regulation of miwifery in ritish Columbia. Canaian Meical ssociation Journal, 166(3), Reason: Not applicable. Mixe proviers in stuy group (physicians an miwives in home births). Khan-Neelofur, D., Gulmezoglu, M., & Villar, J. (1998). Who shoul provie routine antenatal care for lowrisk women, an how often? systematic review of ranomise controlle trials. WHO ntenatal Care Trial Research Group. Paeiatric an Perinatal Epiemiology, 12(Suppl 2), Reason: Not applicable. Stuies inclue ha mixe proviers in both groups. Murphy, P.., & Fullerton, J. (1998). Outcomes of intene home births in nurse-miwifery practice: prospective escriptive stuy. Obstetrics an Gynecology, 92(3), Reason: Not applicable. Lacks comparative analysis with physician outcomes. Paine, L. L., Johnson, T. R., Lang, J. M., Gagnon, D., Declercq, E. R., DeJoseph, J., et al. (2000). comparison of visits an practices of nurse-miwives an obstetrician-gynecologists in ambulatory care settings. Journal of Miwifery & Women s Health, 45(1), Reason: Have better quality, more relevant research. This was a single practice in which miwives care primarily for pregnant patients, while physicians care primarily for gynecology patients. Pang, J. W., Heffelfinger, J. D., Huang, G. J., eneetti, T. J., & Weiss, N. S. (2002). Outcomes of planne home births in Washington State: Obstetrics an Gynecology, 100(2), Reason: Inclues unplanne an possibly unattene home births. Inclues unplanne home births with unqualifie attenants. Inclues preterm births. While it reports a high perinatal mortality, 10 of the 20 babies who ie ha congenital heart isease. lso, some home births may have been chosen with the parents knowing the prognosis. Selection criteria of home births stuie never establishe. Reinharz, D., lais, R., Fraser, W. D., & Contanriopoulos,. P. (2000). Cost-effectiveness of miwifery services vs. meical services in Quebec. L Equipe Evaluation es Projets-Pilotes Sages-Femmes. Canaian Journal of Public Health, 91(1), Reason: Not relevant. Does not compare care accoring to provier. Stone, P. W., Zwanziger, J., Hinton Walker, P., & uenting, J. (2000). Economic analysis of two moels of low-risk maternity care: freestaning birth center compare to traitional care. Research in Nursing & Health, 23(4), Reason: Not relevant. Does not compare care accoring to provier. MYRI SGDY LESLIE is a faculty member in the School of Nursing at Georgetown University in Washington, DC, an the former Director of the Nurse-Miwifery Service an irth Center at the University of California at San Diego. SHRON STORTON is a psychotherapist who specializes in women s mental health an trauma recovery. She is also a member of the CIMS Leaership Team. Step 1: ccess Leslie & Storton 19S

23 THE COLITION FOR IMPROVING MTERNITY SERVICES: EVIDENCE SIS FOR THE TEN STEPS OF MOTHER-FRIENDLY CRE Step 2: Provies ccurate, Descriptive, Statistical Information bout irth Care Practices The Coalition for Improving Maternity Services STRCT Step 2 of the Ten Steps of Mother-Frienly Care insures that women will have accurate, escriptive, an statistical information about the practices an proceures for birth care at their place of birth, incluing measures of interventions an outcomes. This information provies a founation for making informe ecisions. The rationales an evience in support of this step are presente. Journal of Perinatal Eucation, 16(1 Supplement), 20S 22S, oi: / X Keywors: informe ecision-making, patient choice, patient autonomy, patient rights Step 2: Provies accurate, escriptive, an statistical information to the public about its practices an proceures for birth care, incluing measures of interventions an outcomes. ccurate Information bout irth Practices For a escription an iscussion of the methos use to etermine the evience basis of the Ten Steps of Mother-Frienly Care, see this issue s Methos article by Henci Goer on pages 5S 9S. Proviing accurate information to patients is a feeral requirement uner the Health Insurance Portability an ccountability ct of 1996 (HIP). Chapter 4 of the Consumer Rights an Responsibilities of HIP states (2005): Consumers have the right an responsibility to fully participate in all ecisions relate to their health care. Consumers who are unable to fully participate in treatment ecisions have the right to be represente by parents, guarians, family members, or other conservators. In orer to ensure a consumer s right an ability to participate in treatment ecisions, health-care professionals shoul: Provie patients with easily unerstoo information an opportunity to ecie among treatment options consistent with the informe consent process. Specifically, s Discuss all treatment options with a patient in a culturally competent manner, incluing the option of no treatment at all. s Ensure that persons with isabilities have effective communications with members of the health system in making such ecisions. s Discuss all current treatments a consumer may be unergoing, incluing those alternative treatments that are self-aministere. Evience Grae N N N (Continue ) 20S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

24 (Continue) ccurate Information bout irth Practices Evience Grae Discuss all risks, benefits, an consequences to treatment or nontreatment. Give patients the opportunity to refuse treatment an to express preferences about future treatment ecisions. Discuss the use of avance irectives both living wills an urable powers of attorney for health care with patients an their esignate family members. bie by the ecisions mae by their patients an/or their esignate representatives consistent with the informe consent process. Proviing accurate information an ensuring the right to informe refusal as manate by the merican College of Obstetricians an Gynecologists (COG, 2000): [] physician must isclose to the patient the risks an benefits that a reasonable person in the patient s position woul want to know in orer to make an informe ecision.... Once a patient has been informe of the material risks an benefits involve with a treatment, test, or proceure, that patient has the right to exercise full autonomy in eciing whether to unergo that treatment, test, or proceure or whether to make a choice among a variety of treatments, tests, or proceures. In the exercise of that autonomy, the informe patient also has the right to refuse to unergo any of these treatments, tests, or proceures. Proviing evience-base information about meical proceures oes not harm women (O Cathain, 2002; Stapleton, 2002). N N N NEH C (2 analyses from one stuy) N For more information on the Coalition for Improving Maternity Services (CIMS) an copies of the Mother- Frienly Chilbirth Initiative an accompanying Ten Steps of Mother-Frienly Care, log on to the organization s Web site ( org) or call CIMS toll-free at Iniviuals have a basic human right to personal autonomy, an others must respect this right. This is merely an extension of the emocratic concept of self-government applie to the iniviual. If a person gives his/her consent with complete knowlege of what he/she risks by participating in the research, he/she is allowe to take risks he/she chooses (Committee for the Protection of Human Subjects, 2005). Hospitals an other health-care facilities have evelope Patient ill of Rights ocuments to ensure patients are mae aware of their rights. Integral to most of these ocuments is the provision of accurate ata an information to patients so they may make informe choices about their care (Floria, 2005; Minnesota, 2005; New York, 2005; New Jersey, 2005). ¼ goo, C ¼ weak, N ¼ not applicable, NEH ¼ no evience of harm Quality ¼ aggregate of quality ratings for iniviual stuies Quantity ¼ magnitue of effect, numbers of stuies, an sample size or power Consistency ¼ the extent to which similar finings are reporte using similar an ifferent stuy esigns N N N N N N Members of the CIMS Expert Work Group were: Henci Goer,, Project Director Mayri Sagay Leslie, MSN, CNM Juith Lothian, PhD, RN, LCCE, FCCE my Romano, MSN, CNM Karen Salt, CCE, M Katherine Shealy, MPH, ICLC, RLC Sharon Storton, M, CCHT, LMFT Deborah Woolley, PhD, CNM, LCCE INCLUDED STUDIES merican College of Obstetrics an Gynecologists [COG]. (2000). Informe refusal. Committee Opinion No Committee for the Protection of Human Subjects, San Francisco State University. Retrieve December 14, 2005, from 3-rationale.html Floria Patient ill of Rights. Retrieve December 15, 2005, from billofrights.htm Minnesota Patient ill of Rights. Retrieve December 15, 2005, from consumerinfo/mn_pts_rights_eng_reg.pf New Jersey Patient ill of Rights. Retrieve December 15, 2005, from patientrights.htm New York State Patient ill of Rights. Retrieve December 14, 2005, from consumer/patient/ocs/english.pf Office of Personnel Management, HIP Consumer Rights an Responsibilities. Retrieve December 15, 2005, from O Cathain,., Walters, S. J., Nicholl, J. P., Thomas, K. J., & Kirkham, M. (2002). Use of evience base leaflets to promote informe choice in maternity care: Ranomize controlle trial in everyay practice. MJ, 324(7338), Step 2: ccurate Information CIMS 21S

25 Stapleton, H., Kirkham, M., & Thomas, G. (2002). Qualitative stuy of evience base leaflets in maternity care. MJ, 324(7338), EXCLUDED STUDIES Elbourne, D., Richarson, M., Chalmers, I., Waterhouse, I., & Holt, E. (1987). The Newbury Maternity Care Stuy: ranomize controlle trial to assess a policy of women holing their own obstetric recors. ritish Journal of Obstetrics an Gynaecology, 94(7), Reason: Not applicable. Scope of stuy too narrowly efine. National Commission. (1979). The elmont report: Ethical principles an guielines for the protection of human subjects of research. Washington, DC: U.S. Government Printing Office. Reason: Seminal government ocument; ate of publication oes not affect valiity. 22S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

26 THE COLITION FOR IMPROVING MTERNITY SERVICES: EVIDENCE SIS FOR THE TEN STEPS OF MOTHER-FRIENDLY CRE Step 3: Provies Culturally Competent Care The Coalition for Improving Maternity Services: Karen Salt, CCE, M STRCT Step 3 of the Ten Steps of Mother-Frienly Care insures that women receive care that is sensitive an responsive to the specific beliefs, values, an customs of the mother s ethnicity an religion. The rationale for this step an the evience in support of its value are presente. Journal of Perinatal Eucation, 16(1 Supplement), 23S 24S, oi: / X Keywors: culturally competent care, culturally appropriate services, linguistically appropriate services Step 3: Provies culturally competent care that is, care that is sensitive an responsive to the specific beliefs, values, an customs of the mother s ethnicity an religion. The U.S. Office of Minority Health (2001) efines cultural an linguistic competence as a set of congruent behaviors, attitues, an policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations. Culturally Competent Care Health systems that practice an employ culturally an linguistically appropriate services result in: Less miscommunication ue to language ifferences or variations in cultural unerstaning of health events (nerson, 2003). Evience Grae Increase client satisfaction with an confience in health provier (nerson, 2003). C* N* Increase self-awareness of isease or other health problems an use of appropriate interventions (nerson, 2003). Culturally competent care can reuce the incience of meical errors that result from language or cultural misunerstanings. Consequently, this moel may potentially improve care by eliminating unnecessary or uplicate testing, as well as inappropriate treatment recommenations (nerson, 2003; Flores, 2005). N* N* (Continue ) For a escription an iscussion of the methos use to etermine the evience basis of the Ten Steps of Mother-Frienly Care, see this issue s Methos article by Henci Goer on pages 5S 9S. For more information on the Coalition for Improving Maternity Services (CIMS) an copies of the Mother- Frienly Chilbirth Initiative an accompanying Ten Steps of Mother-Frienly Care, log on to the organization s Web site ( org) or call CIMS toll-free at Step 3: Culturally Competent Care Salt 23S

27 Members of the CIMS Expert Work Group were: Henci Goer,, Project Director Mayri Sagay Leslie, MSN, CNM Juith Lothian, PhD, RN, LCCE, FCCE my Romano, MSN, CNM Karen Salt, CCE, M Katherine Shealy, MPH, ICLC, RLC Sharon Storton, M, CCHT, LMFT Deborah Woolley, PhD, CNM, LCCE (Continue) Culturally Competent Care Proviing services an care sensitive to clients cultural beliefs an language may positively affect how they access services an care in the future. Clients with limite English proficiency may experience compromise care if they nee, but o not receive, interpretation services or if a hoc interpreters (incluing chilren an marginally bilingual health-service proviers who are not traine as professional translators) attempt to facilitate meical translation (Flores, 2005; Tanon, 2005). ¼ goo, ¼ fair, C ¼ weak, N ¼ not applicable, NEH ¼ no evience of harm, SR ¼ systematic review Quality ¼ aggregate of quality ratings for iniviual stuies Quantity ¼ magnitue of effect, numbers of stuies, an sample size or power Consistency ¼ the extent to which similar finings are reporte using similar an ifferent stuy esigns *only one stuy Evience Grae NEH C REFERENCE U. S. Office of Minority Health. (2001). National stanars for culturally an linguistically appropriate services in health care. Washington, D.C.: U.S. Department of Health an Human Services. INCLUDED STUDIES nerson, L. M., Scrimshaw, S. C., Fullilove, M. T., Fieling, J. E., & Norman, J. (2003). Culturally competent healthcare systems: systematic review. merican Journal of Preventive Meicine, 24(35), Flores, G. (2005). The impact of meical interpreter services on the quality of health care: systematic review. Meical Care Research an Review, 62(3), Tanon, S. D., Parillo, K. M., & Keefer, M. (2005). Hispanic women s perceptions of patient-centereness uring prenatal care: mixe-metho stuy. irth, 32(4), EXCLUDED STUDIES lpers, R. R., & Zoncha, R. (1996). Comparison of cultural competence an cultural confience of senior nursing stuents in a private southern university. Journal of Cultural Diversity, 3(1), Reason: Stuy supersee by nerson et al. (2003) SR. arton, J.., & rown, N. J. (1992). Evaluation stuy of a transcultural iscovery learning moel. Public Health Nursing, 9(4), Reason: Not relevant. etancourt, J. R., Green,. R., Carrillo, J. E., & naneh- Firempong, I. O., (2003). Defining cultural competence: practical framework for aressing racial/ ethnic isparities in health an health care. Public Health Reports, 118(4), Reason: Not relevant. lackfor, J., & Street,. (2002). Cultural conflict: The impact of western feminism(s) on nurses caring for women of non-english speaking backgroun. Journal of Clinical Nursing, 11(5), Reason: Not relevant. Dronin, J., & Rivet, C. (2003). Training meical stuents to communicate with a linguistic minority group. caemic Meicine: Journal of the association of merican Meical Colleges, 78(6), Reason: Not relevant. Gemson, D. H., shfor,. R., Dickey, L.L., Raymore, S. H., Roberts, J. W., Ehrlich,. G., et al. (1995). Putting prevention into practice. Impact of a multifacete physician eucation program on prevention services in the inner city. rchives of Internal Meicine, 155(20), Reason: Not relevant. Marvel, M. K., Grow, M., & Morphew, P. (1993). Integrating family an culture into meicine: family systems block rotation. Family Meicine, 25(7), Reason: Not relevant. Mayberry, R. M., Mili, F., & Ofili, E. (2000). Racial an ethnic ifferences in access to meical care. Meical Care Research an Review, 57(Suppl), Reason: Stuy supersee by nerson et al. (2003) SR. Nora, L. M., Daugherty, S. R., Mattis-Peterson,., Stevenson, L., & Gooman, L. J. (1994). Improving cross-cultural skills of meical stuents through meical school-community partnerships. The Western Journal of Meicine, 16(2), Reason: Not relevant. Scisney-Matlock, M. (2000). Systematic methos to enhance iversity knowlege gaine: propose path to professional richness. Journal of Cultural Diversity, 7(2), Reason: Not relevant. Speculative eucational proposal. Smith, L. S. (2001). Evaluation of an eucational intervention to increase cultural competence among registere nurses. Journal of Cultural Diversity, 8(2), Reason: Not relevant. St. Clair,., & McKenry, L. (1999). Preparing culturally competent practitioners. The Journal of Nursing Eucation, 38(5), Reason: Not relevant. Stuy presents eucational guielines. Ulrey, K. L., & mason, P. (2001). Intercultural communication between patients an health care proviers: n exploration of intercultural communication effectiveness, cultural sensitivity, stress, an anxiety. Health Communication, 13(4), Reason: Not relevant. Warner, J. R. (2002). Cultural competence immersion experiences: Public health among the Navajo. Nurse Eucator, 27(4), Reason: Not relevant. KREN SLT is an author, chilbirth eucator, oula, an former cochair of the Coalition for Improving Maternity Services. She currently attens Purue University in West Lafayette, Iniana, as a full-time octoral stuent, specializing in nationalism, race, an gener stuies. 24S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

28 THE COLITION FOR IMPROVING MTERNITY SERVICES: EVIDENCE SIS FOR THE TEN STEPS OF MOTHER-FRIENDLY CRE Step 4: Provies the irthing Woman With Freeom of Movement to Walk, Move, ssume Positions of Her Choice The Coalition for Improving Maternity Services: Sharon Storton, M, CCHT, LMFT STRCT Step 4 of the Ten Steps of Mother-Frienly Care insures that women have the freeom to walk, move, an assume positions of their choice uring labor an birth. The rationales an the evience in support of this step are presente. Journal of Perinatal Eucation, 16(1 Supplement), 25S 27S, oi: / X Keywors: movement in labor, secon-stage positioning, maternal choice, maternal satisfaction Step 4: Provies the birthing woman with the freeom to walk, move about, an assume the positions of her choice uring labor an birth (unless restriction is specifically require to correct a complication) an iscourages the use of the lithotomy position. Freeom of movement in labor appears to facilitate the progress of labor an enhance chilbirth satisfaction. Restricting women s movement may have averse effects. For a escription an iscussion of the methos use to etermine the evience basis of the Ten Steps of Mother-Frienly Care, see this issue s Methos article by Henci Goer on pages 5S 9S. Freeom of Movement No evience of harm foun for freeom to ambulate, move about, or change position uring labor an birth when restriction is not require to correct a complication. The lithotomy position reuces bloo flow to the fetus, aversely affecting the fetal heart rate. In aition, the lithotomy position raises levels of maternal stress hormones, thereby reucing uterine contractility an labor progress (Simkin, 2002). mbulation, movement, an changes of position uring the first stage of labor may shorten labor; no evience suggests ambulation increases uration of labor (lbers, 1997; Simkin, 2002). Evience Grae NEH ** (Continue ) For more information on the Coalition for Improving Maternity Services (CIMS) an copies of the Mother- Frienly Chilbirth Initiative an accompanying Ten Steps of Mother-Frienly Care, log on to the organization s Web site ( or call CIMS toll-free at Step 4: Freeom of Movement Storton 25S

29 Members of the CIMS Expert Work Group were: Henci Goer,, Project Director Mayri Sagay Leslie, MSN, CNM Juith Lothian, PhD, RN, LCCE, FCCE my Romano, MSN, CNM Karen Salt, CCE, M Katherine Shealy, MPH, ICLC, RLC Sharon Storton, M, CCHT, LMFT Deborah Woolley, PhD, CNM, LCCE (Continue) Freeom of Movement Women who ambulate uring the first stage of labor were less likely to have a surgical elivery, efine as cesarean section or forceps or vacuum extraction (lbers, 1997). When allowe the freeom to ambulate, move, an change position uring labor an birth, most women choose to o so an fin this to be an effective form of pain relief (DeClerq, 2002; Simkin, 2002). Changes of position uring secon-stage labor incluing ambulation, staning, kneeling, squatting, an the use of a chair or stool in women with epiural analgesia provie no significant reuctions in instrumental an operative elivery, as well as no increase risk of harm to the mother or infant from allowing the mother to use these positions when her muscle tone permitte (Roberts, 2005). Evience Grae N* ** Women who chose a nonsupine position for birth ha shorter secon stages of labor, require less pain relief meication, an ha fewer abnormal fetal heart rate patterns (Simkin, 2002). ** Women who assume a nonsupine position for birth ha fewer perineal injuries (Shorten, 2002; Soong, 2005; Terry, 2006), less vulvar eema, an less bloo loss (Terry, 2006). Hans-an-knees positioning of a woman uring the first stage of labor when her fetus is in a cephalic presentation but occipitoposterior position increase the chance of fetal rotation to the occipitoanterior position an significantly reuce her experience of persistent back pain (Stremler, 2005). Hans-an-knees positioning of a woman, as compare with sitting, uring the secon stage of labor is associate with a more favorable maternal experience an less pain with no significant ifference in the uration of labor (Ragnar, 2006). N* irth attenant preference rather than maternal preference most often inicate maternal position for birth (Shorten, 2002; Soong, 2005; Terry, 2006). ¼ goo, ¼ fair, N ¼ not applicable, NEH ¼ no evience of harm, SR ¼ systematic review Quality ¼ aggregate of quality ratings for iniviual stuies Quantity ¼ magnitue of effect, numbers of stuies, an sample size or power Consistency ¼ the extent to which similar finings are reporte using similar an ifferent stuy esigns *only one stuy **multiple stuies in SR INCLUDED STUDIES lbers, L., nerson, D., Cragin, L., Daniels, S. M., Hunter, C., Seler, K. D., et al. (1997). The relationship of ambulation in labor to operative elivery. Journal of Nurse-Miwifery, 42(1), 4 8. DeClercq, E., Sakala, C., Corry, M., pplebaum, S., & Risher, P. (2002). Listening to mothers: Report of the first national U.S. survey of women s chilbearing experiences. New York: Maternity Center ssociation. Ragnar, I., ltman, D., Tyen, T., & Olsson, S. E. (2006). Comparison of the maternal experience an uration of labor in two upright elivery positions ranomise controlle trial. ritish Journal of Obstetrics an Gynaecology, 113(2), Roberts, C., lgert, C., Cameron, C., & Torvalsen, S. (2005). meta-analysis of upright positions in the secon stage to reuce instrumental eliveries in women with epiural analgesia. cta Obstetricia et Gynecologica Scaninavica, 84, Shorten,., Donsante, J., & Shorten,. (2002). irth position, accoucheur an perineal outcomes: Informing women about choices for vaginal birth. irth, 29(1), Simkin, P., & O Hara, M. (2002). Nonpharmacologic relief of pain uring labor: Systematic reviews of five methos. merican Journal of Obstetrics an Gynecology, 186, S131 S159. Soong,., & arnes, M. (2005). Maternal position at miwife attene birth an perineal trauma: Is there an association? irth, 32(3), Stremler, R., Honett, E., Petryshen, P., Stevens,., Weston, J., & Willan,. R. (2005). Ranomize controlle trial of hans-an-knees positioning for occipitoposterior position in labor. irth, 32(4), S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

30 Terry, R., Wescott, J., O Shea, L., & Kelly, F. (2006). Postpartum outcomes in supine elivery by physicians versus nonsupine elivery by miwives. The Journal of the merican Osteopathic ssociation, 106(4), EXCLUDED STUDIES llahbaia, G., & Vaiya, P. (1992). Why eliver in the supine position? ustralian an New Zealan Journal of Obstetrics & Gynaecology, 32(2), Reason: Data inclue in Gupta (2003). nrews,c.,&chzanowski,m.(2002).maternalposition, labor an comfort. pplie Nursing Research, 3(1), Reason: Data inclue in Simkin (2002). loom, S., McIntire, D., Kelly, M., eimer, H., urpo, R., Garcia, M., et al. (1998). Lack of effect of walking on labor. New Englan Journal of Meicine, 339(2), Reason: Data inclue in Simkin (2002). Carlson, J., Diehl, J., Sachtleben-Murray, M., & McRae, M. (1986). Maternal position uring parturition in normal labor. Obstetrics an Gynecology, 68, Reason: Data inclue in Simkin (2002). Gupta, J., & Hofmeyr, G. (2003). Position in the secon stage of labour for women without epiural anaesthesia. The Cochrane Database of Systematic Reviews, Issue 3. rt. No. CD02006.pub2. DOI: / CD pub2. Reason: Data inclue in Simkin (2002). Rooks S. (1999). Evience-base practice an its application to chilbirth care for low-risk women. Journal of Nurse-Miwifery, 44(4), Reason: Not applicable. No meta-analysis inclue, renering material an article rather than a systematic review. SHRON STORTON is a psychotherapist who specializes in women s mental health an trauma recovery. She is also a member of the CIMS Leaership Team. Step 4: Freeom of Movement Storton 27S

31 THE COLITION FOR IMPROVING MTERNITY SERVICES: EVIDENCE SIS FOR THE TEN STEPS OF MOTHER-FRIENDLY CRE Step 5: Has Clearly Define Policies, Proceures for Collaboration, Consultation, Links to Community Resources The Coalition for Improving Maternity Services: Karen Salt, CCE, M STRCT Step 5 of the Ten Steps of Mother-Frienly Care ensures that the hospital, birth center, or home birth service has clearly efine policies an proceures for collaborating an consulting with other maternity services an for linking the mother an baby to appropriate community services uring both the prenatal an the postpartum perios. The rationales an evience in support of this step are presente. Journal of Perinatal Eucation, 16(1 Supplement), 28S 31S, oi: / X Keywors: continuity of care, collaborative care, continuity of caregivers, breastfeeing support Step 5: Has clearly efine policies an proceures for: For a escription an iscussion of the methos use to etermine the evience basis of the Ten Steps of Mother-Frienly Care, see this issue s Methos article by Henci Goer on pages 5S 9S. collaborating an consulting throughout the perinatal perio with other maternity services, incluing communicating with the original caregiver when transfer from one birth site to another is necessary; an linking the mother an baby to appropriate community resources, incluing prenatal an postischarge follow up an breastfeeing support. Health systems that engage in collaborative an consultative care approaches embrace the tenets of collaborative care an the goals of maintaining continuity of caregivers. Honett (1998) notes that continuity of caregivers can be efine as care provie by the same caregiver or a small group of caregivers throughout the perinatal perio. Collaborative care often incorporates elements of continuity of care; however, Jackson an colleagues (2003) stress that this approach can expan beyon clinical caregivers to collaboration with an among perinatal health eucators, nutrition counselors, an social service agencies. Consequently, both approaches provie benefits to chilbearing women. Step 5: Has clearly efine policies an proceures for: collaborating an consulting throughout the perinatal perio with other maternity services, incluing communicating with the original caregiver when transfer from one birth site to another is necessary. 28S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

32 Policies for Collaboration/Consultation Evience Grae Women who receive continuity of care uring pregnancy, chilbirth, an the postpartum perio: give birth with less frequent use of epiural anesthesia (Jackson, 2003). N* have babies who are less likely to nee resuscitation after birth (Honett, 1998). have fewer episiotomies (Honett, 1998; Jackson, 2003). Women who o not receive continuity of care: are less likely to feel supporte uring labor (Honett, 1998). N* are less likely to feel prepare for parenthoo (Honett, 1998). N* are less likely to iscuss pregnancy an postpartum concerns an problems with their caregiver(s) (Honett, 1998). Collaborative care approaches also affect health outcomes. Women receiving this kin of care may have: more spontaneous vaginal births (Jackson, 2003). N* more access to supportive postpartum services (Jackson, 2003). N* collaborative care moel can affect the health of high-risk babies by reucing the likelihoo of eveloping life-threatening illnesses, requiring amission to a peiatric intensive care unit an shortening the length of stay in such units (royles, 2000). Retaining high-risk pregnant women an high-risk infants (e.g., infants weighing less than 2,000 g) in lower-level hospitals significantly increases mortality rates from potentially preventable causes in low- an very-low-birth-weight infants (Mayfiel, 1990; Powell, 1995). Failure to implement a collaborative system can affect appropriate patient transfer to facilities offering a higher level of care. For example, Wall (2004) reporte that nonclinical factors, such as proceural or economic issues, can affect the transfer of babies weighing less than 1,250 g from one birth facility to another (Wall, 2004). ¼ goo, ¼ fair, N ¼ not applicable, NE ¼ no evience of benefit Quality ¼ aggregate of quality ratings for iniviual stuies Quantity ¼ magnitue of effect, numbers of stuies, an sample size or power Consistency ¼ the extent to which similar finings are reporte using similar an ifferent stuy esigns *only 1 stuy N* N* N* Members of the CIMS Expert Work Group were: For more information on the Coalition for Improving Maternity Services (CIMS) an copies of the Mother- Frienly Chilbirth Initiative an accompanying Ten Steps of Mother- Frienly Care, log on to the organization s Web site ( or call CIMS toll-free at Henci Goer,, Project Director Mayri Sagay Leslie, MSN, CNM Juith Lothian, PhD, RN, LCCE, FCCE my Romano, MSN, CNM Karen Salt, CCE, M Katherine Shealy, MPH, ICLC, RLC Sharon Storton, M, CCHT, LMFT Deborah Woolley, PhD, CNM, LCCE INCLUDED STUDIES royles, R. S., Tyson, J. E., Heyne, E. T., Heyne, R. J., Hickman, J. F., Swint, M., et al. (2000). Comprehensive follow-up care an life-threatening illnesses among high-risk infants: ranomize controlle trial. Journal of the merican Meical ssociation, 284(16), Honett, E. D. (1998). Continuity of caregivers for care uring pregnancy an chilbirth (Review). Cochrane Database Systematic Reviews, Issue 3. rt. No: CD DOI: / CD Jackson, D. J., Lang, J. M., Swartz, W. H., Ganiats, T. G., Fullerton, J., Ecker, J., et al. (2003). Outcomes, safety, an resource utilization in a collaborative care birth Step 5: Community Resources Salt 29S

33 center program compare with traitional physicianbase perinatal care. merican Journal of Public Health, 93(6), Mayfiel, J.., Rosenblatt, R.., alwin, L. M., Chu, J., & Logerfo, J. P. (1990). The relation of obstetrical volume an nursery level to perinatal mortality. merican Journal of Public Health, 80(7), Powell, S. L., Holt, V. L., Hickok, D. E., Easterling, T., & Connell, F.. (1995). Recent changes in elivery site of low-birth-weight infants in Washington: Impact on birth weight-specific mortality. merican Journal of Obstetrics an Gynecology, 173, Wall, S. N., Hanler,. S., & Park, C. G. (2004). Hospital factors an nontransfer of small babies: marker of perinatal care? Journal of Perinatology, 24, EXCLUDED STUDIES rousseau, D. C., Meurer, J. R., Isenberg, M. L., Kuhn, E. M., & Gorelick, M. H. (2004). ssociation between infant continuity of care an peiatric emergency epartment utilization. Peiatrics, 113, Reason: Small sample size. Cabana, M. D., & Jee, S. H. (2004). Does continuity of care improve patient outcomes? The Journal of Family Practice, 53(12), Reason: Not relevant. This systematic review (SR) ealt with sustaine continuity of care in outpatient settings. D mour, D., Goulet, L., Labaie, J. F., ernier, L., & Pineault, R. (2003). ccessibility, continuity an appropriateness: Key elements in assessing integration of perinatal services. Health & Social Care in the Community, 11(5), Reason: Not relevant. Stuy evaluate whether care met clinical guielines. Davey, M., rown, S., & ruinsma, F. (2005). What is it about antenatal continuity of caregiver that matters to women? irth, 32(4), Reason: Poorly esigne: 1) Survey response rate from targete participants was less than the stanar 70%, calling into question its generalizability; an 2) questionnaire was sent 5 months after birth an relie exclusively on participants memories of who they saw (an the nature of their appointments) uring their antenatal care. Ekström,. E., Wiström,., & Nissen, E. (2006). Does continuity of care by well-traine breastfeeing counselors improve a mother s perception of support? irth, 33(2), Reason: Poorly esigne. Inconsistency in follow-through of stuy protocol by the health professionals traine in breastfeeing counseling an support renere it ifficult to assess impact of intervention. Gill, J. M., & Mainous,. G., III. (1998). The role of provier continuity in preventing hospitalizations. rchives of Family Meicine, 7, Reason: Have better-quality, more relevant research. Mainous,. G., III, Goowin, M.., & Stange, K. C. (2004). Patient-physician share experiences an value patients place on continuity of care. nnals of Family Meicine, 2(5), Reason: Have betterquality, more relevant research. Morgan, E. D., Pasquarella, M., & Holman, J. R. (2004). Continuity of care an patient satisfaction in a family practice clinic. The Journal of the merican oar of Family Practice, 17, Reason: Have betterquality, more relevant research. Rooks, J. P., Weatherby, N. L., & Ernst, E. K. M. (1992). The National irth Center Stuy. Part III Intrapartum an immeiate postpartum an neonatal complications an transfers, postpartum an neonatal care, outcomes, an client satisfaction. Journal of Nurse- Miwifery, 37(6), Reason: Stuy supersee by Honett (1998) SR. Saultz, J. W., & lbeaiwi, W. (2004). Interpersonal continuity of care an patient satisfaction: critical review. nnals of Family Practice, 2(5), Reason: Not relevant. Review inclue stuies of military veterans an retire men. Walenström, U., rown, S., McLachlan, H., Forster, D., & rennecke, S. (2000). Does team miwife care increase satisfaction with antenatal, intrapartum, an postpartum care? ranomize controlle trial. irth, 27(3), Reason: Have better-quality, more relevant research. Step 5: Has clearly efine policies an proceures for: linking the mother an baby to appropriate community resources, incluing prenatal an postischarge follow-up an breastfeeing support. Policies for Linking to Community Resources In-home postpartum care improves breastfeeing outcomes for mothers of term newborns (McKeever, 2002). Postischarge home visits are cost-effective for reucing nee for hospital-base services for ehyration an jaunice (Paul, 2004). Evience Grae N* N (Continue ) 30S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

34 (Continue) Policies for Linking to Community Resources Peer support receive consistently throughout the perinatal perio improves breastfeeing initiation an uration (Haier, 2000; Kistin, 1994). Evience Grae Volunteer (unpai) postpartum support oes not affect breastfeeing outcomes (Graffy, 2004). N* ¼ goo, ¼ fair, N ¼ not applicable Quality ¼ aggregate of quality ratings for iniviual stuies Quantity ¼ magnitue of effect, numbers of stuies, an sample size or power Consistency ¼ the extent to which similar finings are reporte using similar an ifferent stuy esigns *only 1 stuy INCLUDED STUDIES Graffy, J., Taylor, J., Williams,., & Elrige, S. (2004). Ranomise controlle trial of support from volunteer counsellors for mothers consiering breast feeing. MJ, 328, 1 6. Haier, R., shworth,., Kabir, I., & Huttly, S. (2000). Effect of community-base peer counselors on exclusive breastfeeing practices in Dhaka, anglaesh: ranomize controlle trial. Lancet, 356, Kistin, N., bramson, R., & Dublin, P. (1994). Effect of peer counselors on breastfeeing initiation, exclusivity, an uration among low-income urban women. Journal of Human Lactation, 10(1), McKeever, P., Stevens,., Miller, K., MacDonell, J., Gibbins, S., Guerriere, D., et al. (2002). Home versus hospital breastfeeing support for newborns: ranomize controlle trial. irth, 29(4), Paul, I., Phillips, T., Wiome, M., & Hollenbeak, C. (2004). Cost-effectiveness of postnatal home nursing visits for prevention of hospital care for jaunice an ehyration. Peiatrics, 114(4), EXCLUDED STUDIES Gagnon,., Dougherty, G., Jimenez, V., & Leuc, N. (2002). Ranomize trial of postpartum care after hospital ischarge. Peiatrics, 109(6), Reason: Not relevant. No group i not receive postpartum care. Morrell, C., Spiby, H., Stewart, P., Walters, S., & Morgan,. (2000). Costs an effectiveness of community postnatal support workers: Ranomize controlle trial. MJ, 321, Reason: Not applicable. Control group receive extensive postnatal support as well. KREN SLT is an author, chilbirth eucator, oula, an former cochair of the Coalition for Improving Maternity Services. She currently attens Purue University in West Lafayette, Iniana, as a full-time octoral stuent, specializing in nationalism, race, an gener stuies. Step 5: Community Resources Salt 31S

35 THE COLITION FOR IMPROVING MTERNITY SERVICES: EVIDENCE SIS FOR THE TEN STEPS OF MOTHER-FRIENDLY CRE Step 6: Does Not Routinely Employ Practices, Proceures Unsupporte by Scientific Evience The Coalition for Improving Maternity Services: Henci Goer, Mayri Sagay Leslie, MSN, CNM my Romano, MSN, CNM STRCT Step 6 of the Ten Steps of Mother-Frienly Care aresses two issues: 1) the routine use of interventions (shaving, enemas, intravenous rips, withholing foo an fluis, early rupture of membranes, an continuous electronic fetal monitoring; an 2) the optimal rates of inuction, episiotomy, cesareans, an vaginal births after cesarean. Rationales for compliance an systematic reviews are presente. Journal of Perinatal Eucation, 16(1 Supplement), 32S 64S, oi: / X Keywors: laborpreparation;perinealshaving,labor;enema,labor;intravenousrip,averseeffects;intravenousrip,labor; intravenous nutrition, labor; obstetric proceures, averse effects; NPO, labor; nutrition, labor; oral intake, labor; amniotomy artificial rupture of membranes; electronic fetal monitoring; intrapartum cariotocography; elective inuction; labor inuction; labor inuce; spontaneous labor rates; rates of inuction; inuction an averse effects; maternal satisfaction an inuction; episiotomy, averse effects; episiotomy, meian; episiotomy, meiolateral; episiotomy rate; cesarean; cesarean rate; cesarean, averse effects; vaginal birth, averse effects; obstetric birth, averse effects; pelvic-floor ysfunction; urinary incontinence; anal incontinence; vaginal birth after cesarean (VC); VC rates; elective repeat cesarean; VC an inuction of labor Step 6: Does not routinely employ practices an proceures that are unsupporte by scientific evience, incluing, but not limite to, the following: For a escription an iscussion of the methos use to etermine the evience basis of the Ten Steps of Mother-Frienly Care, see this issue s Methos article by Henci Goer on pages 5S 9S. shaving [for vaginal birth]; enemas; intravenous rips (IVs); withholing nourishment or water; early rupture of membranes; an [continuous] electronic fetal monitoring [intrapartum cariotocography]. Limits interventions, as follows: inuction rate of 10% or less; episiotomy rate of 20% or less, with a goal of 5% or less; 32S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

36 total cesarean rate of 10% or less in community hospitals, an 15% or less in tertiary hospitals; an vaginal birth after cesarean (VC) rate of 60% or more, with a goal of 75% or more. Step 6: Does not routinely employ practices an proceures that are unsupporte by scientific evience, incluing, but not limite to, the following: shaving [for vaginal birth] Shaving for Vaginal irth The rationale for pubic an perineal shaving for vaginal birth is to prevent infection. However: maternal infection rates o not iffer between shave an unshave women (asevi, 2001). shave women experience irritation, reness, superficial scratches, burning, an itching (asevi, 2001). INCLUDED STUDIES asevi, V., & Lavener, T. (2001). Routine perineal shaving on amission in labour. Cochrane Database of Systematic Reviews, (1), CD EXCLUDED STUDIES Johnston, R.., & Siall, R. S. (1922). Is the usual metho of preparing patients for elivery beneficial or necessary? merican Journal of Obstetrics an Gynecology, 4, Reason: Data inclue in asevi (2001). Kantor, H. I., Rember, R., Tabio, P., & uchanon, R. (1965). Value of shaving the puenal-perineal Evience Grae ¼ goo, ¼ fair, C ¼ weak, N ¼ not applicable, NE ¼ no evience of benefit Quality ¼ aggregate of quality ratings for iniviual stuies Quantity ¼ magnitue of effect, numbers of stuies, an sample size or power Consistency ¼ the extent to which similar finings are reporte using similar an ifferent stuy esigns *only 1 stuy **multiple stuies in systematic review (SR) NE ** C (Only 1 stuy, an it oes not report averse effects in the unshave group.) N* area in elivery preparation. Obstetrics & Gynecology, 25, Reason: Data inclue in asevi (2001). Kovavisarach, E., & Jirasettasiri, P. (2005). Ranomise controlle trial of perineal shaving versus hair cutting in parturients on amission in labor. Journal of the Meical ssociation of Thailan, 88(9), Reason: No untreate group. Women were either shave or ha pubic hair trimme to 0.5 cm. ll receive enema an episiotomy, both of which coul affect infection rates. Therefore, this trial is not generalizable to populations not unergoing these interventions. For more information on the Coalition for Improving Maternity Services (CIMS) an copies of the Mother- Frienly Chilbirth Initiative an accompanying Ten Steps of Mother-Frienly Care, log on to the organization s Web site ( or call CIMS toll-free at Members of the CIMS Expert Work Group were: Henci Goer,, Project Director Mayri Sagay Leslie, MSN, CNM Juith Lothian, PhD, RN, LCCE, FCCE my Romano, MSN, CNM Karen Salt, CCE, M Katherine Shealy, MPH, ICLC, RLC Sharon Storton, M, CCHT, LMFT Deborah Woolley, PhD, CNM, LCCE Step 6: Does not routinely employ practices an proceures that are unsupporte by scientific evience, incluing, but not limite to, the following: enemas Step 6: Scientific Evience Goer, Leslie, & Romano 33S

37 Enemas Evience Grae lthough these rationales are given for the routine use of enemas: NE Routine enema oes not enhance ilation rate (Rutgers, 1993; Tzeng, 2005). C Enemas o not affect moe of vaginal elivery (Tzeng, 2005). C N* Enemas o not reuce neonatal infection rates (Tzeng, 2005). C N* Enemas o not reuce maternal infection rates (Tzeng, 2005). C N* Some women islike having enemas (Rutgers, 1993). C C N* ¼ goo, ¼ fair, C ¼ weak, N ¼ not applicable, NE ¼ no evience of benefit Quality ¼ aggregate of quality ratings for iniviual stuies Quantity ¼ magnitue of effect, numbers of stuies, an sample size or power Consistency ¼ the extent to which similar finings are reporte using similar an ifferent stuy esigns *only 1 stuy INCLUDED STUDIES Rutgers, S. (1993). Hot, high an horrible. Shoul routine enemas still be given to women in labour? The Central frican Journal of Meicine, 39(6), Tzeng, Y. L., Shih, Y. J., Teng, Y. K., Chiu, C. Y., & Huang, M.Y.(2005).Enemapriortolabor:controversialroutine in Taiwan. The Journal of Nursing Research, 13(4), EXCLUDED STUDIES Cuervo,L.G.,ernalMel,P.,&Menoza,N.(2006).Effectsof high volume saline enemas vs no enema uring labour The N-Ma ranomise controlle trial [ISRCTN ]. MC Pregnancy an Chilbirth, 6,8.Reason: Does not exclue women having cesarean sections. Unerpowere to etect ifferences in maternal an neonatal infections. Extremely high combine infection rate of 46% not generalizable to other populations. Fails to consier possible averse effects of highvolume enemas. Cuervo, L. G., Roriguez, M. N., & Delgao, M.. (2000). Enemas uring labor. Cochrane Database of Systematic Reviews, (2), CD Reason: Poorly esigne: The SR inclues only 2 trials, one of them the lea author s unpublishe thesis ata. Of the 30 outcomes reporte, 28 of them are base on his ata alone. The SR reports 10 separate outcomes relate to neonatal infection, all but one from the lea author s trial alone, so it is harly surprising that a couple of them turn out to be significant just by chance. No evience presente that lea author s trial evaluate whether infective organisms were colonic in origin. Investigators reject trials for arbitrary reasons such as too few perinatal infections without proviing sources to support what the expecte rate shoul be. Kovavisarach, E., & Sringamvong, W. (2005). Enema versus no-enema in pregnant women on amission in labor: ranomize controlle trial. Journal of the Meical ssociation of Thailan, 88(12), Reason: Does not istinguish between forme stool an iarrhea when measuring contamination. Forme stool is less likely to contaminate the perineum. Does not efine infection. No power calculation. Ninety percent episiotomy rate. Presence or absence of episiotomy woun coul affect perineal infection rates; therefore, stuy not generalizable to populations not experiencing high episiotomy rates. Step 6: Does not routinely employ practices an proceures that are unsupporte by scientific evience, incluing, but not limite to, the following: intravenous rips (IVs) 34S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

38 Intravenous Drips Evience Grae Common rationales for routine intravenous rips (IVs) inclue supplying fluis, proviing an open vein in case of emergency, an, in some cases, supplying calories. However: If women rink an eat as esire in labor, the nee for routine NE replacement fluis an calories isappears. No stuy foun showing that having an IV in place improves outcomes. NE IVs can cause iscomfort an istress (Simkin, 1986; Tourangeau, 1999). C IVs interfere with mobility. There is no formal evience of this, other than a survey reporting that of women who sai they were confine to be, two thirs gave being connecte to things as the reason (Declercq, 2002). However, the nee to eal with the IV line an pole necessarily interferes with mobility. Infusing excessive volumes of IV flui can cause: anemia a,b (Carvalho, 1991; Kempen, 1990). C reuctions in colloi osmotic pressure a,c (Park, 1996). C N* Infusing electrolyte-free solutions can cause hyponatremia a, C (Higgins, 1996; Stratton, 1995). Infusing glucose-containing solutions can cause neonatal hyperglycemia a,e (Norstrom, 1995). ( Connecte to things coul mean monitoring equipment as well as IVs.) N* ¼ goo, ¼ fair, C ¼ weak, N ¼ not applicable, NE ¼ no evience of benefit Quality ¼ aggregate of quality ratings for iniviual stuies Quantity ¼ magnitue of effect, numbers of stuies, an sample size or power Consistency ¼ the extent to which similar finings are reporte using similar an ifferent stuy esigns *only 1 stuy a These stuies reporte few or no clinical symptoms; however, trials were small an participants ha uncomplicate pregnancies. This means both that trials woul be unlikely to etect uncommon events an that participants woul be unlikely to experience them. b One concern with anemia is that it increases maternal risks (e.g., the likelihoo of neeing transfusion) shoul there be a hemorrhage. c Reuctions in colloi osmotic pressure can lea to eema, incluing flui in maternal an fetal lungs (Park, 1996). Hyponatremia can lea to transient neonatal tachypnea an, in severe cases, to seizure in the newborn an seizures or coma in the mother (Grylack, 1984; Stratton, 1995). e Stuies publishe before 1990 confirm that infusing glucose solutions can cause fetal hyperglycemia an that this can result in hypoglycemia after birth when the maternal source of glucose is withrawn (Grylack, 1984; Philipson, 1987). C C N* REFERENCES Grylack, L. J., Chu, S. S., & Scanlon, J. W. (1984). Use of intravenous fluis before cesarean section: Effects on perinatal glucose, insulin, an soium homeostasis. Obstetrics & Gynecology, 63(5), Park, G. E., Hauch, M.., Curlin F., Datta, S., & aer,. M. (1996). The effects of varying volumes of crystalloi aministration before cesarean elivery on maternal hemoynamics an colloi osmotic pressure. nesthesia an nalgesia, 83(2), Philipson, E. H., Kalhan, S. C., Riha, M. M., & Pimentel, R. (1987). Effects of maternal glucose infusion on fetal aci-base status in human pregnancy. merican Journal of Obstetrics an Gynecology, 157(4, Pt. 1), Stratton, J. F., Stronge, J., & oylan, P. C. (1995). Hyponatraemia an non-electrolyte solutions in labouring primigravia. European Journal of Obstetrics, Gynecology, an Reprouctive iology, 59(2), INCLUDED STUDIES Carvalho, J. C., Mathias, R. S., Senra, W. G., Torres, M. L., am, C., Vasconcelos,., et al. (1991). Hemoglobin concentration variation an bloo volume expansion uring epiural anesthesia for cesarean section. Regional nesthesia, 16(1S), 73. Step 6: Scientific Evience Goer, Leslie, & Romano 35S

39 Declercq, E., Sakala, C., Corry, M. P., pplebaum, S., & Risher, P. (2002). Listening to mothers: Report of the first national U.S. survey of women s chilbearing experiences. New York: Maternity Center ssociation. Higgins, J., Gleeson, R., Holohan, M., Cooney, C., & Darling, M.(1996). Maternalanneonatalhyponatraemia: comparison of Hartmanns solution with 5% extrose for the elivery of oxytocin in labour. European Journal of Obstetrics, Gynecology, an Reprouctive iology, 68(1 2), Kempen, P. M., & Tick, R. C. (1990). Hemoilution, regional blockan cesarean section. Regionalnesthesia, 15(1S), 9. Norstrom, L., rulkumaran, S., Chua, S., Ratnam, S., Ingemarsson,I.,Kublickas,M.,etal.(1995).Continuous maternal glucose infusion uring labor: Effects on maternal an fetal glucose an lactate levels. merican Journal of Perinatology, 12(5), Park, G. E., Hauch, M.., Curlin, F., Datta, S., & aer,. M. (1996). The effects of varying volumes of crystalloi aministration before cesarean elivery on maternal hemoynamics an colloi osmotic pressure. nesthesia an nalgesia, 83(2), Simkin, P. (1986). Stress, pain, an catecholamines in labor: Part 2. Stress associate with chilbirth events: pilot survey of new mothers. irth, 13(4), Reason: Publishe before 1990, but stuy is a unique source of ata on the issue of maternal satisfaction. Stratton, J. F., Stronge, J., & oylan, P. C. (1995). Hyponatraemia an non-electrolyte solutions in labouring primigravia. European Journal of Obstetrics, Gynecology, an Reprouctive iology, 59(2), Tourangeau,., Carter, N., Tansil, N., McLean,., & Downer, V. (1999). Intravenous therapy for women in labor: Implementation of a practice change. irth, 26(1), EXCLUDED STUDIES Cerri, V., Tarantini, M., Zuliani, G., Schena, V., Reaelli, C., & Nicolini, U. (2000). Intravenous glucose infusion in labor oes not affect maternal an fetal aci-base balance. The Journal of Maternal-Fetal Meicine, 9(4), Reason: No information on how participants ranomize. No power calculation. Substantial ifference in sizes of groups. Stuy fails to evaluate all important outcomes. Garite, T. J., Weeks, J., Peters-Phair, K., Pattillo, C., & rewster, W. R. (2000). ranomize controlle trial of the effect of increase intravenous hyration on the course of labor in nulliparous women. merican Journal of Obstetrics an Gynecology, 183(6), Reason: Not relevant. Stuy conclues that increasing the rate of intravenous hyration ecreases the incience of prolonge labor, but the step manates abanoning routine IV hyration an permitting laboring women to self-regulate oral intake of fluis. Hauch, M.., Gaiser, R. R., Hartwell,. L., & Datta, S. (1995). Maternal an fetal colloi osmotic pressure following flui expansion uring cesarean section. Critical Care Meicine, 23(3), Reason: Have better quality an more recent research. The following year, the same group publishe another stuy measuring colloi osmotic pressure (Park, 1996), which is inclue. Step 6: Does not routinely employ practices an proceures that are unsupporte by scientific evience, incluing, but not limite to, the following: withholing nourishment or water Oral Intake The rationale for enying oral intake is to reuce the risk of pulmonary aspiration an the morbiity an mortality that can result from aspiration shoul cesarean section uner general anesthesia be require. However: The likelihoo of aspiration is vanishingly small. In the Netherlans, where women are freely allowe oral intake (Scheepers, 1998), the mortality rate from aspiration uring cesarean surgery is 1.8 per 100,000 (Schuitemaker, 1997). Using the cesarean rate in first-time mothers (31%) as a proxy for unplanne cesareans (Declercq, 2002), multiplying it by the percentage of cesareans performe uner general anesthesia in the Unite States (15%) (Hawkins, 1997), an multiplying that result by 1.8 per 100,000, the likelihoo of a fe woman unergoing an unplanne cesarean uner general anesthesia ying of pulmonary aspiration calculates to 8 per 10 million or 1 in 1,250,000. Moreover, this is a worst-case scenario. The Dutch stuy oes not report the conition of the women at the time they unerwent surgery. stuy of 13,400 emergency surgeries uner general anesthesia reporte no eaths from aspiration in patients in reasonably goo health (S physical status rankings of I or II) (Warner, 1993). No length of time since previous oral intake guarantees having a stomach volume below the anger threshol of 25 ml (Carp, 1992). Evience Grae NE (Continue ) 36S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

40 (Continue) Oral Intake Depriving women of oral fluis causes moerate to high stress in many laboring women; epriving them of foo causes moerate to high stress in some women (Simkin, 1986). Evience Grae Calories ingeste in labor are igeste (Kubli, 2002; Scrutton, 1999). ¼ goo, ¼ fair, C ¼ weak, N ¼ not applicable, NE ¼ no evience of benefit Quality ¼ aggregate of quality ratings for iniviual stuies Quantity ¼ magnitue of effect, numbers of stuies, an sample size or power Consistency ¼ the extent to which similar finings are reporte using similar an ifferent stuy esigns *only 1 stuy C (It is possible that most of the women reporting that oral flui eprivation cause stress were not receiving IV fluis.) C N* INCLUDED STUDIES Carp, H., Jayaram,., & Stoll, M. (1992). Ultrasoun examination of the stomach contents of parturients. nesthesia an nalgesia, 74(5), Declercq, E., Sakala, C., Corry, M. P., pplebaum, S., & Risher, P. (2002). Listening to mothers: Report of the first national U.S. survey of women s chilbearing experiences. New York: Maternity Center ssociation. Hawkins, J. L., Gibbs, C. P., Orleans, M., Martin-Salvaj, G., & eaty,. (1997). Obstetric anesthesia work force survey, 1981 versus nesthesiology, 87(1), Kubli, M., Scrutton, M. J., See, P. T., & O Sullivan, G. (2002). n evaluation of isotonic sport rinks uring labor. nesthesia an nalgesia, 94(2), , table of contents. Scheepers, H. C., Esse, G. G., & rouns, F. (1998). spects of foo an flui intake uring labour. Policies of miwives an obstetricians in The Netherlans. European Journal of Obstetrics, Gynecology, an Reprouctive iology, 78(1), Schuitemaker, N., van Roosmalen, J., Dekker, G., van Dongen, P., van Geijn, H., & Gravenhorst, J.. (1997). Maternal mortality after cesarean section in The Netherlans. cta Obstetricia et Gynecologica Scaninavica, 76(4), Scrutton, M. J., Metcalfe, G.., Lowy, C., See, P. T., & O Sullivan, G. (1999). Eating in labour. ranomise controlle trial assessing the risks an benefits. naesthesia, 54(4), Simkin, P. (1986). Stress, pain, an catecholamines in labor: Part 2. Stress associate with chilbirth events: pilot survey of new mothers. irth, 13(4), Reason: Publishe before 1990, but stuy is a unique source of ata on the issue of maternal satisfaction. Warner, M.., Warner, M. E., & Weber, J. G. (1993). Clinical significance of pulmonary aspiration uring the perioperative perio. nesthesiology, 78(1), EXCLUDED STUDIES garwal,., Chari, P., & Singh, H. (1989). Flui eprivation before operation. The effect of a small rink. naesthesia, 44(8), Reason: Have better quality research on same topic. Participants were not pregnant women. CNM Data Group. (1999). Oral intake in labor. Trens in miwifery practice. The CNM Data Group, Journal of Nurse-Miwifery, 44(2), Reason: Stuy not relevant. Hawkins, J. L., Koonin, L. M., Palmer, S. K., & Gibbs, C. P. (1997). nesthesia-relate eaths uring obstetric elivery in the Unite States, nesthesiology, 86(2), Reason: Stuy not relevant. Michael, S., Reilly, C. S., & Caunt, J.. (1991). Policies for oral intake uring labour. survey of maternity units in Englan an Wales. naesthesia, 46(12), Reason: Stuy not relevant. Parsons, M., iewell, J., & Nagy, S. (2006). Natural eating behavior in latent labor an its effect on outcomes in active labor. Journal of Miwifery & Women s Health, 51(1), e1 6. Reason: Stuy not relevant. Scheepers, H. C., Thans, M. C., e Jong, P.., Esse, G., Le Cessie, S., & Kanhai, H. (2001). Eating an rinking in labor: The influence of caregiver avice on women s behavior. irth, 28(2), Reason: Stuy not relevant. Tranmer, J. E., Honett, E. D., Hannah, M. E., & Stevens,.J. (2005). The effect of unrestricte oral carbohyrate intake on labor progress. Journal of Obstetric, Gynecologic, an Neonatal Nursing, 34(3), Reason: Stuy unerpowere to etect ifferences in rare averse outcomes. Stuy unerpowere to Step 6: Scientific Evience Goer, Leslie, & Romano 37S

41 etect ifferences in ystocia of less than 38%. Stuy confoune by: restricting oral intake with epiural use an 79% of oral intake group ha epiurals; IV solutions usually containe lactate or glucose; nearly half of oral intake group i not have oral intake; an other factors that coul aversely affect labor progress, incluing epiural anesthesia, inuction, confinement to be. Two thirs of the oral intake group reporte moerate or severe thirst, inicating that they i not, in fact, have free access to oral intake. Step 6: Does not routinely employ practices an proceures that are unsupporte by scientific evience, incluing, but not limite to, the following: early rupture of membranes mniotomy mniotomy is believe to shorten labor an, by so oing, reuce the number of cesarean sections for slow progress an improve neonatal outcomes by reucing exposure to the stress of overly long labors. However: Routine amniotomy shortens mean uration of labor by only a moest amount (1 2 hrs) (Fraser, 1999). Early amniotomy has less effect than amniotomy later in labor (Fraser, 1993). Routine amniotomy fails to reuce the cesarean section rate (Fraser, 1999; Rouse, 1994). Routine amniotomy has no clinically significant neonatal benefits (Fraser, 1999). Routine amniotomy may increase the risk of nonreassuring fetal heart rate (FHR) (Fraser, 1993; Fraser, 1999, Garite, 1993; Mercer, 1995). Early amniotomy may increase the maternal an neonatal infection rate (Fraser, 1999; Mercer, 1995; Rouse, 1994; Soper, 1996). Evience Grae NE a ** N* (Of 10 trials inclue in Fraser [1999], 7 reporte higher cesarean rates in the amniotomy group, 2 reporte lower rates, an 1 small trial ha no cesareans.) a a ** (Fraser [1999] i not fin an increase incience, but reviewers note that a reanalysis, taking into account that amniotomy shortene labor, i increase incience. n increase in episoes of nonreassuring FHR is biologically plausible in that releasing the amniotic flui increases pressure on the fetal hea an umbilical cor uring contractions.) a (Fraser [1999], a SR, i not fin an increase incience, but other stuies fin a strong association between uration of rupture membranes, time, an invasive proceures.) (Continue ) 38S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

42 (Continue) mniotomy Evience Grae mniotomy can lea to umbilical cor prolapse (Roberts, 1997; Usta, 1999). ¼ goo, ¼ fair, NE ¼ no evience of benefit Quality ¼ aggregate of quality ratings for iniviual stuies Quantity ¼ magnitue of effect, numbers of stuies, an sample size or power Consistency ¼ the extent to which similar finings are reporte using similar an ifferent stuy esigns *only 1 stuy **multiple stuies in SR a Ranomize controlle trials (RCTs) of amniotomy an, hence, systematic reviews of those trials suffer from confouning factors that coul affect labor progress, occurrence of averse events (abnormal fetal heart rate, infection, cesarean section), or both, specifically: Substantial proportions of women in the control group, more than half in some cases, also ha amniotomies. Women in the control group were more likely to have oxytocin (Fraser, 1999). Women ha vaginal examinations after membrane rupture an, in some trials, internal monitoring in both arms of the trial. In aition, trials inclue only women with full-term, uncomplicate pregnancies. This means that ifferences between groups might be wier than they appear. First, in stuies where amniotomy appears to be harmless, this might not have been the case ha not so many women in the control group ha amniotomies or ha the baby s ability to withstan stress been less than optimal. Secon, where stuies report harmful effects, the ifference between amniotomy an control group might have been more pronounce. REFERENCE Fraser, W. D., Turcot, L., Krauss, I., & risson-carrol, G. (1999). mniotomy for shortening spontaneous labour. The Cochrane Database of Systematic Reviews, (4), CD INCLUDED STUDIES Fraser, W. D., Marcoux, S., Moutquin, J. M., & Christen,. (1993). Effect of early amniotomy on the risk of ystocia in nulliparous women. The Canaian Early mniotomy Stuy Group. The New Englan Journal of Meicine, 328(16), Fraser,W.D.,Turcot,L.,Krauss,I.,&risson-Carrol,G.(1999). mniotomy for shortening spontaneous labour. The Cochrane Database of Systematic Reviews, (4), CD Garite, T. J., Porto, M., Carlson, N. J., Rumney, P. J., & Reimbol, P.. (1993). The influence of elective amniotomy on fetal heart rate patterns an the course of labor in term patients: ranomize stuy. merican Journal of Obstetrics an Gynecology, 168(6, Pt. 1), ; iscussion Mercer,. M., McNanley, T., O rien, J. M., Ranal, L., & Sibai,. M. (1995). Early versus late amniotomy for labor inuction: ranomize trial. merican Journal of Obstetrics an Gynecology, 173(4), Roberts, W. E., Martin, R. W., Roach, H. H., Perry, K. G., Jr., Martin, J. N., Jr., & Morrison, J. C. (1997). re obstetric interventions such as cervical ripening, inuction of labor, amnioinfusion, or amniotomy associate with umbilical cor prolapse? merican Journal of Obstetrics an Gynecology, 176(6), ; iscussion Rouse, D. J., McCullough, C., Wren,. L., Owen, J., & Hauth, J. C. (1994). ctive-phase labor arrest: a ranomize trial of chorioamnion management. Obstetrics & Gynecology, 83(6), Soper, D. E., Mayhall, C. G., & Froggatt, J. W. (1996). Characterization an control of intraamniotic infection in an urban teaching hospital. merican Journal of Obstetrics an Gynecology, 175(2), ; iscussion Usta, I. M., Mercer,. M., & Sibai,. M. (1999). Current obstetrical practice an umbilical cor prolapse. merican Journal of Perinatology, 16(9), EXCLUDED STUDIES arrett, J. F., Savage, J., Phillips, K., & Lilfor, R. J. (1992). Ranomize trial of amniotomy in labour versus the intention to leave membranes intact until the secon stage. ritish Journal of Obstetrics an Gynaecology, 99(1), 5 9. Reason: Quality poor enough to invaliate results. The Cochrane SR (Fraser, 1999) exclue the stuy because of inequality between groups suggesting error in ranomization technique. risson-carroll, G., Fraser, W., reart, G., Krauss, I., & Thornton, J. (1996). The effect of routine early amniotomy on spontaneous labor: meta-analysis. Obstetrics & Gynecology, 87(5, Pt. 2), Reason: This SR of amniotomy was supersee by the Cochrane SR (Fraser, 1999). Cammu, H., & Van Eeckhout, E. (1996). ranomise controlle trial of early versus elaye use of amniotomy an oxytocin infusion innulliparouslabour. ritish Journalof Obstetrics an Gynaecology, 103(4), Reason: This is an RCT of ctive Management of Labor. Step 6: Does not routinely employ practices an proceures that are unsupporte by scientific evience, incluing, but not limite to, the following: [continuous] electronic fetal monitoring [intrapartum cariotocography] Step 6: Scientific Evience Goer, Leslie, & Romano 39S

43 Continuous Electronic Fetal Monitoring Compare with intermittent auscultation, routine continuous electronic fetal monitoring (EFM) in low-risk women fails to reuce perinatal eath rates, low PGR scores, amissions to special care nursery, or the incience of cerebral palsy (CP) (Thacker, 2001). Compare with intermittent auscultation, routine continuous EFM significantly reuces the incience of neonatal seizure (Thacker, 2001). However, that benefit was foun in a trial in an institution that manates a high-ose oxytocin protocol for any woman not progressing at the average rate (MacDonal, 1985). The likelihoo of uterine hyperstimulation an, therefore, the likelihoo of istressing the fetus rise as oxytocin osage rises. more physiologic regimen might reuce or eliminate the benefit of closer monitoring. In any case, no long-term benefits were foun (Grant, 1989). Of the other nine trials in the Cochrane review, seven faile to fin a ifference an two foun a nonsignificant ifference, but all nine were unerpowere to etect a ifference in this rare outcome. Compare with intermittent auscultation, routine continuous EFM in women in preterm labor fails to improve neonatal outcomes (Luthy, 1987). No trials coul be foun evaluating routine continuous EFM with epiural analgesia, physiologic oxytocin augmentation or inuction protocols, or VC labors. Other than one RCT of continuous EFM in women in preterm labor, publishe in 1987 (see above), no RCTs have evaluate the benefits versus harms of routine continuous EFM in women with fetuses at high risk of being unable to tolerate labor. The association between FHR patterns in labor an conition at birth is weak (Milsom, 2002; Sameshima, 2004). The association between conition at birth an long-term averse outcome is weak (Low, 1990; Milsom, 2002; Yukin, 1994). Therefore, the association between FHR patterns an neurologic injury is necessarily weak. This means that refinements of EFM technology such as computer analysis of fetal heart rate tracings or fetal electrocariogram analysis are extremely unlikely to improve its ability to preict encephalopathy or CP. Compare with intermittent auscultation, routine continuous EFM increases the likelihoo of vaginal instrumental birth an cesarean section (Thacker, 2001). The excess risk of cesarean section is greater in low-risk pregnancies an in trials with no follow-up test to verify istress (Thacker, 2001). The use of internal fetal monitoring increases the likelihoo of infection (Soper, 1996). In aition, the fact that EFM increases the likelihoo of cesarean surgery means it necessarily increases the likelihoo of infection because cesarean surgery increases the incience of infection over vaginal birth (Maternity Center ssociation (MC), 2004). In cases where membranes are intact, internal EFM involves amniotomy. mniotomy may increase the likelihoo of episoes of nonreassuring FHR (see Step 6, p. 38S). Continuous EFM necessarily interferes with mobility. There is no formal evience of this, other than a survey reporting that of women who sai they were confine to be, two thirs gave being connecte to things as the reason (Declercq, 2002). Monitoring from a central unit necessarily ecreases interaction between nurses an laboring women. Supportive care is highly value by laboring women (Honett, 2002). Evience Grae ** C N* enefit unknown; harm establishe (see below) See Step 6, p. 38S for graes. ( Connecte to things coul mean IVs as well as monitoring equipment.) N* (Continue ) 40S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

44 (Continue) Continuous Electronic Fetal Monitoring The amission test strip that is, the routine use of continuous EFM for a limite perio at hospital amission fails to provie neonatal benefits. However, it increases the use of continuous EFM (Impey, 2003; Mires, 2001). The amission test strip may increase the likelihoo of operative birth (cesarean plus vaginal instrumental birth) (Impey, 2003; Mires, 2001). Evience Grae ¼ goo, ¼ fair, C ¼ weak, N ¼ not applicable Quality ¼ aggregate of quality ratings for iniviual stuies Quantity ¼ magnitue of effect, numbers of stuies, an sample size or power Consistency ¼ the extent to which similar finings are reporte using similar an ifferent stuy esigns *only 1 stuy **multiple stuies in SR C (Mires [2001] reporte that an amission test strip increase the likelihoo of operative elivery; Impey [2003] i not fin an increase. Differences between trial results may reflect iffering philosophies an policies among stuy institutions.) INCLUDED STUDIES Declercq, E., Sakala, C., Corry, M. P., pplebaum, S., & Risher, P. (2002). Listening to mothers: Report of the first national U.S. survey of women s chilbearing experiences. New York: Maternity Center ssociation. Grant,.,O rien,n.,joy,m.t.,hennessy,e.,&macdonal, D. (1989). Cerebral palsy among chilren born uring thedublinranomisetrialofintrapartummonitoring. Lancet, 2(8674), Reason: Publishe before 1990butthisstuyfollowsupakeytrialofEFMinclue in Thacker (2001) systematic review. Honett, E. (2002). Pain an women s satisfaction with the experience of chilbirth: systematic review. merican Journal of Obstetrics an Gynecology, 186, S160 S172. Impey, L., Reynols, M., MacQuillan, K., Gates, S., Murphy, J., & Sheil, O. (2003). mission cariotocography: ranomise controlletrial. Lancet, 361(9356), Low, J..,Muir, D. W., Pater,E..,&Karchmar,E. J.(1990). The association of intrapartum asphyxia in the mature fetuswithnewbornbehavior. mericanjournalofobstetrics an Gynecology, 163(4, Pt. 1), Luthy, D.., Shy, K. K., van elle, G., Larson, E.., Hughes, J. P., eneetti, T. J., et al. (1987). ranomize trial of electronic fetal monitoring in preterm labor. Obstetrics & Gynecology, 69(5), Reason: Publishe before 1990 but trial inclue in Thacker (2001) systematic review an is a unique source of ata on this topic. MacDonal, D., Grant,., Sherian-Pereira, M., oylan, P., & Chalmers, I. (1985). TheDublinranomize controlle trial of intrapartum fetal heart rate monitoring. merican Journal of Obstetrics an Gynecology, 152(5), Reason: Stuy publishe before 1990 but trial inclue in Thacker (2001) systematic review an raises key point not aresse in that review. Maternity Center ssociation. (2004). Harms of cesarean versus vaginal birth: systematic review. In Chilbirth Connection, What every pregnant woman nees to know about cesarean section (booklet; 2n eition 2006, revise; pp ). New York: uthor. lso, retrieve December 17, 2006, from org/article.asp?ck¼10271 Milsom, I., Lafors, L., Thiringer, K., Niklasson,., Oeback,., & Thornberg, E. (2002). Influence of maternal, obstetric an fetal risk factors on the prevalence of birth asphyxia at term in a Sweish urban population. cta Obstetricia et Gynecologica Scaninavica, 81(10), Mires, G., Williams, F., & Howie, P. (2001). Ranomise controlle trial of cariotocography versus Doppler auscultation of fetal heart at amission in labour in low risk obstetric population. MJ, 322(7300), ; iscussion Sameshima,H.,Ikenoue,T.,Ikea,T.,Kamitomo,M.,& Ibara, S. (2004). Unselecte low-risk pregnancies an the effect of continuous intrapartum fetal heart rate monitoring on umbilical bloo gases an cerebral palsy. merican Journal of Obstetrics an Gynecology, 190(1), Soper, D. E., Mayhall, C. G., & Froggatt, J. W. (1996). Characterization an control of intraamniotic infection in an urban teaching hospital. merican Journal of Obstetrics an Gynecology, 175(2), ; iscussion Thacker, S.., & Stroup, D. F. (2001). Continuous electronic heart rate monitoring for fetal assessment uring labor. Cochrane Database of Systematic Reviews (2), CD Yukin, P. L., Johnson,., Clover, L. M., & Murphy, K. W. (1994). Clustering of perinatal markers of birth Step 6: Scientific Evience Goer, Leslie, & Romano 41S

45 asphyxia an outcome at age five years. ritish Journal of Obstetrics an Gynaecology, 101(9), EXCLUDED STUDIES aawi, N., Kurinczuk, J. J., Keogh, J. M., lessanri, L. M., O Sullivan, F., urton, P. R., et al. (1998). Intrapartum risk factors for newborn encephalopathy: The Western ustralian case-control stuy. MJ, 317(7172), Reason: Not relevant. Cheyne, H., Dunlop,., Shiels, N., & Mathers,. M. (2003). ranomise controlle trial of amission electronic fetal monitoring in normal labour. Miwifery, 19(3), Reason: Poorly esigne. Stuy was unerpowere. Nelson, K.., Dambrosia, J. M., Ting, T. Y., & Grether, J. K. (1996). Uncertain value of electronic fetal monitoring in preicting cerebral palsy. The New Englan Journal of Meicine, 334(10), Reason: Not relevant. Step 6: Limits interventions, as follows: inuction rate of 10% or less For the purposes of this ocument, inuce labors are efine as labors starte by artificial means of whatever kin. They are associate with an increase incience of averse outcomes compare with labors of spontaneous onset; however, it is possible that, in some instances, this increase may result from meical complications that may have le to the use of inuction. In orer to etermine averse effects relate to the proceure itself, this section is confine to stuies of elective inuction that is, inuction for nonmeical reasons such as convenience. Inuction of Labor Evience Grae When compare with similar populations beginning labor spontaneously, elective inuctions result in the following maternal outcomes: increase use of analgesia (oulvain, 2001). N* increase use of epiural anesthesia (oulvain, 2001; Cammu, 2002; Glantz, 2005; Heinberg, 2002; Maslow, 2000; Prysak, 1998; Vahratian, 2005; van Gemun, 2003). increase incience of nonreassuring fetal heart rate patterns (Glantz, 2005). N* increase or equivalent incience of intrapartum fever (Glantz, 2005; Luthy, 2004). increase incience of shouler ystocia (Dublin, 2000). N* increase or equivalent incience of vaginal instrumental birth (vacuum extractor or forceps birth) (Cammu, 2002; Dublin, 2000; Glantz, 2005; Vahratian, 2005; van Gemun, 2003). increase risk of cesarean section for all mothers (oulvain, 2001; Cammu, 2002; Glantz, 2005; Hoffman, 2006; Maslow, 2000; Prysak, 1998; Vahratian, 2005; van Gemun, 2003). increase risk of cesarean section for nulliparous women (Cammu, 2002; Dublin, 2000; Glantz, 2005; Hoffman, 2006; Luthy, 2004; Maslow, 2000; Prysak, 1998; Seyb, 1999; van Gemun, 2003; Vrouenraets, 2005; Yeast, 1999). increase risk of cesarean section for multiparous women (Hoffman, 2006; van Gemun, 2003). In aition, the following factors increase the risk of cesarean with elective inuction: cervical ripening is require an/or the ishop s score is less than 5 (Heinberg, 2002; Prysak, 1998; Vahratian, 2005; Vrouenraets, 2005). (Continue ) 42S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

46 (Continue) Inuction of Labor prior cesarean section (see Step 6, p. 56S) age 25 years or oler. The risk increases further at age 35 years or oler. (Ecker, 2001; Luthy, 2004; Maslow, 2000; Vrouenraets, 2005). Evience Grae use of epiural analgesia (Prysak, 1998; Seyb, 1999; Vrouenraets, 2005). boy mass inex (MI) greater than 31 (Seyb, 1999; Vrouenraets, 2005). When compare with similar populations beginning labor spontaneously, elective inuctions result in the following neonatal outcomes: more or comparable numbers of low-birth-weight infants (<2,500 g) (Vrouenraets, 2005; Heinberg, 2002). increase nee for neonatal resuscitation (oulvain, 2001) N* increase or equivalent incience of amission to neonatal intensive care units (oulvain, 2001; Cammu, 2002; Prysak, 1998). increase nee for neonatal phototherapy to treat jaunice (oulvain, 2001). N* When compare with similar populations beginning labor spontaneously, elective inuctions result in increase costs (Maslow, 2000). N* When compare with similar populations beginning labor spontaneously, elective inuctions result in an increase length of hospital stay (Heinberg, 2002; Glantz, 2005; van Gemun, 2003; Vrouenraets, 2005). The Worl Health Organization convene an international consensus conference on appropriate use of technology for birth. Participants evaluate national inuction rates with respect to neonatal outcomes an etermine that rates higher than 10% coul not be justifie (Worl Health Organization, 1985; M. Wagner, personal communication, ugust 8, 2005). large stuy of a moel of care attempting to achieve maximum health outcomes with the minimal use of meical intervention reporte a 10% inuction rate (Johnson, 2005). The stuy comprise 5,418 women intening home birth who reache term with a live fetus an who ha not been referre for pregnancy complications. Of those, 90% achieve spontaneous labor without inuction. ecause the vast majority of inuctions are one electively or for postates, suspecte macrosomia, or prelabor rupture of membranes at term all categories that coul potentially apply to this population the percentage of inuctions that might have been one uring the preterm perio woul have been small. Therefore, this population serves as a reasonable proxy for an achievable inuction rate overall. ¼ goo, ¼ fair, N ¼ not applicable Quality ¼ aggregate of quality ratings for iniviual stuies Quantity ¼ magnitue of effect, numbers of stuies, an sample size or power Consistency ¼ the extent to which similar finings are reporte using similar an ifferent stuy esigns *only 1 stuy N* Step 6: Scientific Evience Goer, Leslie, & Romano 43S

47 REFERENCES en-haroush,., Yogev, Y., ar, J., Glickman, J., Kaplan, H., & Ho, M. (2004). Inicate labor inuction with vaginal prostaglanin E2 increases the risk of cesarean section even in multiparous women with no previous cesarean section. Journal of Perinatal Meicine, 32(1), Peck, P. (2003, pril). Preinuction cervical ripening significantly increases risk of cesarean. Mescape Meical News. Retrieve December 17, 2006, from INCLUDED STUDIES oulvain, M., Marcoux, S., ureau, M., Fortier, M., & Fraser, W. (2001). Risks of inuction of labour in uncomplicate term pregnancies. Paeiatric an Perinatal Epiemiology, 15(2), Cammu, H., Martens, G., Ruyssinck, G., & my, J. J. (2002). Outcome after elective labor inuction in nulliparous women: a matche cohort stuy. merican Journal of Obstetrics an Gynecology, 186(2), Dublin, S., Lyon-Rochelle, M., Kaplan, R. C., Watts, D. H., & Critchlow, C. W. (2000). Maternal an neonatal outcomes after inuction of labor without an ientifie inication. merican Journal of Obstetrics an Gynecology, 183(4), Ecker,J.L.,Chen,K.T.,Cohen,.P.,&Riley,L.E.,& Lieberman, E. S. (2001). Increase risk of cesarean elivery with avancing maternal age: Inications an associate factors in nulliparous women. merican Journal of Obstetrics an Gynecology, 185(4), Glantz, J. C. (2005). Elective inuction vs. spontaneous labor associations an outcomes. The Journal of Reprouctive Meicine, 50(4), Heinberg, E. M., Woo, R.., & Chambers, R.. (2002). Elective inuction of labor in multiparous women. Does it increase the risk of cesarean section? The Journal of Reprouctive Meicine, 47(5), Hoffman, M. K., Vahratian,., Sciscione,. C., Troenle, J. T., & Zhang, J. (2006). Comparison of labor progression between inuce an noninuce multiparous women. Obstetrics & Gynecology, 107(5), Johnson, K. C., & Daviss,.. (2005). Outcomes of planne home births with certifie professional miwives: Large prospective stuy in North merica. MJ, 330(7505), Luthy, D.., Malmgren, J.., & Zingheim, R. W. (2004). Cesarean elivery after elective inuction in nulliparous women: The physician effect. merican Journal of Obstetrics an Gynecology, 191(5), Maslow,. S., & Sweeny,. L. (2000). Elective inuction of labor as a risk factor for cesarean elivery among low-risk women at term. Obstetrics & Gynecology, 95(6, Pt. 1), Prysak, M., & Castronova, F. C. (1998). Elective inuction versus spontaneous labor: case-control analysis of safety an efficacy. Obstetrics & Gynecology, 92(1), Seyb, S. T., erka, R. J., Socol, M. L., & Dooley, S. L. (1999). Risk of cesarean elivery with elective inuction of labor at term in nulliparous women. Obstetrics & Gynecology, 94(4), Vahratian,., Zhang, J., Troenle, J. F., Sciscione,. C., & Hoffman, M. K. (2005). Labor progression an risk of cesarean elivery in electively inuce nulliparas. Obstetrics & Gynecology, 105(4), van Gemun, N. Hareman,. Scherjon, S.., & Kanhai, H. H. H. (2003). Intervention rates after elective inuction of labor compare to labor with a spontaneous onset. matche cohort stuy. Gynecologic an Obstetric Investigation, 56(3), Vrouenraets, F. P., Roumen, F. J., Dehing, G. J., van en kker, E. S., arts, M. J., & Scheve, J. T. (2005). ishop score an risk of cesarean elivery after inuction of labor in nulliparous women. Obstetrics & Gynecology, 105(4), Worl Health Organization. (1985). ppropriate technology for birth. Lancet, 2(8452), Reason: Publishe before 1990, but a key source of ata on this issue. Yeast, J. D., Jones,., & Poskin, M. (1999). Inuction of labor an the relationship to cesarean elivery: review of 7001 consecutive inuctions. merican Journal of Obstetrics an Gynecology, 180(3, Pt. 1), EXCLUDED STUDIES mano, K., Saito, K., Shoa, T., Tani,., Yoshihara, H., & Nishijima, M. (1999). Elective inuction of labor at 39 weeks of gestation: prospective ranomize trial. The Journal of Obstetrics an Gynaecology Research, 25(1), Reason: nalysis not performe by intention to treat; significant crossover in both groups an lack of information on protocol, inclusion, an exclusion criteria. Kaufman, K. E., ailit, J. L., & Grobman, W. (2002). Elective inuction: n analysis of economic an health consequences. merican Journal of Obstetrics an Gynecology, 187(4), Reason: This provies a ecision-tree analysis, but the variation in significant factors affecting outcomes from one stuy to another in the elective inuction literature makes it challenging to make probability assumptions that can be applie to the general population. Macer, J.., Macer, C. L., & Chan, L. S. (1992). Elective inuction versus spontaneous labor: retrospective stuy of complications an outcome. merican Journal of Obstetrics an Gynecology, 166(6, Pt. 1), ; iscussion Reason: Have more recent research. Nielsen,P.E.,Howar,.C.,Hill,C.C.,Larson,P.L., Hollan,R.H.,&Smith,P.N.(2005).Comparison of elective inuction of labor with favorable ishop scores versus expectant management: ranomize clinical trial. The Journal of Maternal- Fetal & Neonatal Meicine, 18(1), Reason: Stuy stoppe early; final numbers with limite power. Stuy can only etect a ifference at a three-fol level of increase in the risk for cesarean section. 44S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

48 Wigton, T. R., & Wolk,. M. (1994). Elective an routine inuction of labor. retrospective analysis of 274 cases. The Journal of Reprouctive Meicine, 39(1), Reason: Stuy compares one type of noninicate inuction to another (elective versus postates) as escribe by the authors. This review is limite to stuies that compare elective inuction with spontaneous vaginal birth. Step 6: Limits interventions, as follows: episiotomy rate of 20% or less, with a goal of 5% or less The RCTs of liberal versus restricte use of episiotomy testify to the ifficulties of changing entrenche practice. In most trials, sizeable percentages of women in the restrict episiotomy arm were given episiotomies. Of the seven RCTs conucte to ate, the episiotomy rate in the restrictive arm was 10% or less in only two an exceee 30% in four (Hartmann, 2005). Proper ata analysis of an RCT emans that investigators keep participants with their assigne group ( intent to treat ) regarless of actual treatment. To o otherwise woul efeat ranom allotment, the principal avantage of this stuy esign. In trials where treatment epens little on clinician jugment, few protocol violations are likely to occur, an crossover between groups is rarely an issue. However, where this is not thecaseanwhereclinicianopinionfavorstheintervention asisthecasewithmanycliniciansan episiotomy high crossover rates can occur, causing a serious problem with ata interpretation. y commingling the treatments, a high egree of protocol violation ecreases the power of the stuy to etect ifferences between groups. This can make it falsely appear that no ifference exists between groups when, in fact, it oes. For example, because many women in the restrictive use of episiotomy armofthesolerctofmeianepisiotomyhaepisiotomies, an intent to treat analysis showe no ifference between groups in the incience of anal sphincter tears (Klein, 1992). In fact, an episiotomy precee all but one of the 53 anal injuries. Clinician preference for performing episiotomy causes a seconary problem in establishing a goal episiotomy rate base on ata from the RCTs. The 20% rate establishe in the Coalition for Improving Maternity Services s Mother-Frienly Chilbirth Initiative came from the best available evience at the time: the Cochrane systematic review. However, as can be seen below, much lower rates than this can be supporte as upper limitations for performing this proceure. Episiotomy lthough these rationales are given for routine or frequent use of episiotomy, in fact, compare with no episiotomy: Neither meian nor meiolateral episiotomy reuces the incience of anal sphincter lacerations (Eason, 2000; Hartmann, 2005; Huelist, 2005; Larsson, 1991; MC, 2004; Renfrew, 1998). Neither meian nor meiolateral episiotomy improves neonatal outcomes (rgentine Episiotomy Trial Collaborative Group, 1993; Dannecker, 2004; Klein, 1992). Neither meian nor meiolateral episiotomy causes less pain than spontaneous tears (Eason, 2000; Hartmann, 2005; Renfrew, 1998). Neither meian nor meiolateral episiotomies heal better or faster than spontaneous tears (Hartmann, 2005; Klein, 1994). Neither meian nor meiolateral episiotomy prevents urinary stress incontinence in either the short- or the long-term (Eason, 2000; Ewings, 2005; Hartmann, 2005; MC, 2004; Renfrew, 1998). Evience Grae NE (Continue ) Step 6: Scientific Evience Goer, Leslie, & Romano 45S

49 (Continue) Episiotomy Neither meian nor meiolateral episiotomy prevents anal incontinence (Hartmann, 2005; MC, 2004). Neither meian nor meiolateral episiotomy preserves pelvic floor strength (Eason, 2000; Hartmann, 2005; MC, 2004; Renfrew, 1998). Neither meian nor meiolateral episiotomy improves sexual functioning (Eason, 2000; Hartmann, 2005; MC, 2004; Renfrew, 1998). Episiotomy causes more pain than spontaneous tears (Hartmann, 2005; Klein, 1994; Larsson, 1991). Women with episiotomies experience more problems with healing compare with women experiencing spontaneous lacerations (Larsson, 1991; McGuinness, 1991). Women with intact perineums experience the least pain, have the strongest pelvic floors, an experience the best sexual functioning after chilbirth (Klein, 1994). oth meian an meiolateral episiotomy aversely affect sexual functioning (Hartmann, 2005; Klein, 1994). Meian episiotomy preisposes to anal sphincter lacerations (Eason, 2000; Klein, 1992, 1994; Renfrew, 1998). nal sphincter injury is associate with anal sphincter weakness an efects seen on ultrasoun. nal sphincter weakness or efect increases the risk of anal incontinence (MC, 2004). oth meian an meiolateral episiotomy increase the risk of anal incontinence (Hartmann, 2005; MC, 2004). Evience Grae Meian episiotomy weakens the pelvic floor (Klein, 1994). N* Performing meiolateral episiotomy for imminent tear oes not ecrease anal injury rates (Dannecker, 2004; Larsson, 1991). (Performing meian episiotomy for this reason woul increase anal sphincter laceration rates because of its preisposition to exten.) voiing meian episiotomy uring vaginal instrumental birth (forceps or vacuum extraction) reuces the likelihoo of anal laceration (Combs, 1990; Helwig, 1993). Episiotomy rates in mixe-risk, mixe-parity women can be less than 1% among all provier types (obstetricians, family practitioners, miwives) (lbers, 2005). Episiotomy rates in low-risk, mixe-parity women can be 5% or less (Johnson, 2005; MC, 2004). Episiotomy rates in low-risk nulliparous women can average 9% an can be as low as 2% (MC, 2004). ¼ goo, ¼ fair, N ¼ not applicable, NE ¼ no evience of benefit Quality ¼ aggregate of quality ratings for iniviual stuies Quantity ¼ magnitue of effect, numbers of stuies, an sample size or power Consistency ¼ the extent to which similar finings are reporte using similar an ifferent stuy esigns *only 1 stuy **multiple stuies in SR N* ** N to reporting a rate N to reporting a rate N to reporting a rate N to reporting a rate N to reporting a rate N to reporting a rate 46S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

50 REFERENCES Hartmann, K., Viswanathan, M., Palmieri, R., Gartlehner, G., Thorp, J., Jr., & Lohr, K. N. (2005). Outcomes of routine episiotomy: systematic review. The Journal of the merican Meical ssociation, 293(17), Klein, M. C., Gauthier, R. J., Jorgensen, S. H., Robbins, J. M., Kaczorowski, J., Johnson,., et al. (1992, July). Does episiotomy prevent perineal trauma an pelvic floor relaxation? The Online Journal of Current Clinical Trials, Doc. No. 10 (6,019 wors; 65 paragraphs). INCLUDED STUDIES lbers, L. L., Seler, K. D., erick, E. J., Teaf, D., & Peralta, P. (2005). Miwifery care measures in the secon stage of labor an reuction of genital tract trauma at birth: ranomize trial. Journal of Miwifery & Women s Health, 50(5), rgentine Episiotomy Trial Collaborative Group. (1993). Routine vs. selective episiotomy: ranomise controlle trial. Lancet, 342( ), Reason: Trial inclue in systematic reviews but reports an outcome not aresse in that review. Combs, C.., Robertson, P.., & Laros, R. K., Jr. (1990). Risk factors for thir-egree an fourth-egree perineal lacerations in forceps an vacuum eliveries. merican Journal of Obstetrics an Gynecology, 163(1, Pt. 1), Dannecker, C., Hillemanns, P., Strauss,., Hasbargen, U., Hepp, H., & nthuber, C. (2004). Episiotomy an perineal tears presume to be imminent: Ranomize controlle trial. cta Obstetricia et Gynecologica Scaninavica, 83(4), Eason,E.,Labrecque,M.,Wells,G.,&Felman,P.(2000). Preventing perineal trauma uring chilbirth: systematic review. Obstetrics & Gynecology, 95(3), Ewings, P., Spencer, S., Marsh, H., & O Sullivan, M. (2005). Obstetric risk factors for urinary incontinence an preventative pelvic floor exercises: Cohort stuy an neste ranomize controlle trial. Journal of Obstetrics an Gynaecology, 25(6), Hartmann, K., Viswanathan, M., Palmieri, R., Gartlehner, G., Thorp, J., Jr., & Lohr, K. N. (2005). Outcomes of routine episiotomy: systematic review. The Journal of the merican Meical ssociation, 293(17), Helwig, J. T., Thorp, J. M., Jr., & owes, W.., Jr. (1993). Does miline episiotomy increase the risk of thir- an fourth-egree lacerations in operative vaginal eliveries? Obstetrics & Gymecology, 82(2), Huelist, G., Gelle n, J., Singer, C., Ruecklinger, E., Czerwenka, K., Kanolf, O., et al. (2005). Factors preicting severe perineal trauma uring chilbirth: Role of forceps elivery routinely combine with meiolateral episiotomy. merican Journal of Obstetrics an Gynecology, 192(3), Johnson, K. C., & Daviss,.. (2005). Outcomes of planne home births with certifie professional miwives: Large prospective stuy in North merica. MJ, 330(7505), Klein, M. C., Gauthier, R. J., Jorgensen, S. H., Robbins, J. M., Kaczorowski, J., Johnson,., et al. (1992, July). Does episiotomy prevent perineal trauma an pelvic floor relaxation? The Online Journal of Current Clinical Trials, Doc. No. 10, (6,019 wors; 65 paragraphs). Reason: Trial inclue in systematic reviews but reports an outcome not aresse in that review. Klein, M. C., Gauthier, R. J., Robbins, J. M., Kaczorowski, J., Jorgensen, S. H., Franco, E. D., et al. (1994). Relationship of episiotomy to perineal trauma an morbiity, sexual ysfunction, an pelvic floor relaxation. merican Journal of Obstetrics an Gynecology, 171(3), Larsson, P. G., Platz-Christensen, J. J., ergman,., & Wallstersson, G. (1991). vantage or isavantage of episiotomy compare with spontaneous perineal laceration. Gynecologic an Obstetric Investigation, 31(4), Reason: Trial inclue in Hartmann (2005) systematic review but reports an outcome not aresse in that review. Maternity Center ssociation. (2004). Harms of cesarean versus vaginal birth: systematic review. In Chilbirth Connection, What every pregnant woman nees to know about cesarean section (booklet; 2n eition 2006, revise; pp ). New York: uthor. lso, retrieve December 17, 2006, from org/article.asp?ck¼10271 McGuinness, M., Norr, K., & Nacion, K. (1991). Comparison between ifferent perineal outcomes on tissue healing. Journal of Nurse-Miwifery, 36(3), Renfrew, M. J., Hannah, W., lbers, L., & Floy, E. (1998). Practices that minimize trauma to the genital tract in chilbirth: systematic review of the literature. irth, 25(3), EXCLUDED STUDIES oner-ler,., oner, K., Kimberger, O., Wagenbichler, P., & Mayerhofer, K. (2003). Management of the perineum uring forceps elivery. ssociation of episiotomy with the frequency an severity of perineal trauma in women unergoing forceps elivery. The Journal of Reprouctive Meicine, 48(4), Reason: Poorlywritten.Thewaytheataare presente makes it impossible to etermine the relationship between episiotomy of either type an vaginal instrumental birth or between epiural an vaginal instrumental birth. Carroli, G., & elizan, J. (1999). Episiotomy for vaginal birth. The Cochrane Database of Systematic Reviews, (3), CD Reason: Stuy supersee by Hartmann (2005). Casey,. M., Schaffer, J. I., loom, S. L., & Heartwell, D. D. (2005). Obstetric anteceents for postpartum pelvic floor ysfunction. merican Journal of Obstetrics an Gynecology, 192(5), Reason: No information provie on frequency or severity of symptoms. Mean elapse time between birth an postpartum survey is 3 months with a range of 2 weeks Step 6: Scientific Evience Goer, Leslie, & Romano 47S

51 Chilbirth Connection s lert ocument, NIH Cesarean Conference: Interpreting Meeting an Meia Reports (upate October 2006), contains a cogent analysis of the flaws an weaknesses of the March 2006 NIH State-ofthe-Science Conference. View Chilbirth Connection s ocument online at org/article.asp?ck¼10375 to 7 months. Six months or more is a more reasonable time frame in which to evaluate pelvic floor ysfunction. Dannecker, C., Hillemanns, P., Strauss,., Hasbargen, U., & Hepp, H. (2005). Episiotomy an perineal tears presume to be imminent: The influence on the urethral pressure profile, analmanometric an other pelvic floor finings Follow-up stuy of a ranomize controlle trial. cta Obstetricia et Gynecologica Scaninavica, 84(1), Reason: This seconary analysis of an RCT of liberal versus restrictive meiolateral episiotomy reporte urinary an anal incontinence accoring to the intent to treat. However, half the 27 women in the restrictive arm who were followe up ha an episiotomy, an 17% of the 34 women who were followe up in the liberal arm i not. Stuy unerpowere to etect ifferences in incontinence. No evaluation of frequency or severity of incontinence. Step 6: Limits interventions, as follows: Ecker, J. L., Tan, W. M., ansal, R. K., ishop, J. T., & Kilpatrick, S. J. (1997). Is there a benefit to episiotomy at operative vaginal elivery? Observations over ten years in a stable population. merican Journal of Obstetrics an Gynecology, 176(2), Reason: Poorly esigne. Stuy was confoune by a change in episiotomy type over 10-year course of stuy. Eltorkey, M. M., & Nuaim, M.. (1994). Episiotomy, elective or selective: report of a ranom allocation trial. Journal of Obstetrics an Gynaecology, 14, Reason: Stuy ata inclue in Hartmann (2005). Note: This stuy is not easily obtainable. It is not inexe in PubMe. Kettle, C. (2005). Perineal care. Clinical Evience, (13), Reason: Seconary source. Summarizes Carroli (1999), a SR that has been supersee by Hartmann (2005), plus Dannecker (2004) for the only outcome relevant here. total cesarean rate of 10% or less in community hospitals, an 15% or less in tertiary hospitals Current arguments articulate in the March 2006 National Institutes of Health (NIH) State-ofthe-Science Conference Statement against setting a goal cesarean rate rest on four premises (NIH, 2006): Planne cesarean surgery is as safe or nearly as safe as vaginal birth provie women limit family size to one or two chilren (p. 12). Planne cesarean surgery is less risky than unplanne cesarean surgery (p. 6). Cesarean section may prevent urinary incontinence (p. 6). Currently recommene rate limits are opinion base an artificial (p. 4). s this portion of Step 6 makes clear, cesarean section significantly increases the risk of a long list of averse outcomes in mothers an babies, some of them catastrophic. It is true that planne cesarean surgery reuces the risk of certain harms compare with unplanne surgery. Nonetheless, the woman still emerges with a uterine scar an substantial possibility of ense surgical ahesions, both of which can have long-term consequences for her future health an reprouction. s can be seen below, cesarean section offers little protection from urinary or anal incontinence in the chilbearing years an none at all in oler women. Even the minimal short-term benefits are reporte in stuies that i not take into account the effects of moifiable elements of conventional obstetric management in injuring an weakening the pelvic floor. Chief among these are both meian an meiolateral episiotomy an vaginal instrumental elivery (MC, 2004). Other flaws that make it ifficult to etermine the true excess risk, if any, of vaginal birth are (MC, 2004): Definition of incontinence: Stuies often combine women with mil symptoms with more severe problems or fail to istinguish frequent from infrequent symptoms. Time elapse since birth: Symptoms of incontinence become miler an less frequent over time. Moreover, urinary incontinence can often be abate or cure by conservative measures, such as losing weight or engaging in a program of pelvic floor exercises (Groutz, 2004; MC, 2004). Finally, the oft-cite 10 15% maximum cesarean rate first recommene in 1985 by the Worl Health Organization (WHO) after an international consensus conference was neither opinion-base nor artificially erive (WHO, 1985). In fact, it was foune upon the statistic that [c]ountries with some of the lowest perinatal mortality rates in the worl have caesarean section rates of less than 10% (WHO, 1985, p. 437). 48S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

52 s can be seen below as well, that maximum has since been confirme by numerous stuies emonstrating that cesarean rates can be 15% or less in unselecte populations without any eleterious effect on maternal or perinatal outcomes. Inee, women an babies are likely to be healthier because they have not been unnecessarily expose to the harms of cesarean elivery. Cesarean Evience Grae When compare with vaginal birth, cesarean section increases the likelihoo of these averse maternal outcomes: eath (MC, 2004). ** hysterectomy (urrows, 2004; Forna, 2004; Kwee, 2006; MC, 2004; Selo-Ojeme, 2005): Hysterectomy increases the risk of other intraoperative complications (blaer injury) an postoperative complications (hematologic, infectious, pulmonary, genitourinary, gastrointestinal, cariovascular, psychiatric, neurologic) (Forna, 2004; Selo-Ojeme, 2005). thromboembolic events (eep venous clots, pulmonary embolism, stroke) (urrows, 2004; Koroukian, 2004; MC, 2004). surgical injuries (MC, 2004). N*** However, surgical injuries to blaer, bowel, or bloo vessels o not occur in vaginal birth. anesthetic complications (Koroukian, 2004). N* longer postpartum stays (Liu, 2005; MC, 2004). hospital reamissions (Liu, 2005; MC, 2004). hospital reamission sooner after ischarge an for longer uration (Liu, 2005). infections (urrows, 2004; Koroukian, 2004; MC, 2004). N* hemorrhage requiring transfusion (cesarean uring labor) (urrows, 2004). N* more severe an longer lasting postpartum pain (MC, 2004). ** unsatisfactory birth experience (MC, 2004). (Continue ) Step 6: Scientific Evience Goer, Leslie, & Romano 49S

53 (Continue) Cesarean Evience Grae reuce early contact with newborn (MC, 2004). ** negative early reaction to infant (MC, 2004). may cause epression (Carter, 2006; MC, 2004). Inconsistent finings may be explaine by variations in the context in which the cesarean occurs, ifferences in the woman s expectations, an the quality of her birth experience. psychological trauma (MC, 2004). ** poor overall mental health an self-esteem (MC, 2004). poor overall physical functioning (MC, 2004). ** chronic pain (Declercq, 2002; Latthe, 2006; MC, 2004; Nikolajsen 2004). ahesions (Lyell, 2005; Myers, 2005; Phipps, 2005): hesions can cause chronic pain an increase the likelihoo of surgical injury uring future operations. bowel obstruction (MC, 2004). ** When compare with vaginal birth, cesarean section increases the likelihoo of these averse neonatal outcomes: surgical laceration (Dessole, 2004; MC, 2004). respiratory complications serious enough to require amission to a special care nursery (Gerten, 2005; MC, 2004). may increase frequency of special care nursery amission (Fogelson, 2005). N* not breastfeeing/failure of breastfeeing (MC, 2004). ** may increase likelihoo of asthma (Juhn, 2005; Maitra, 2004; MC, 2004). sensitivity to allergens (Laubereau, 2004; Negele, 2004). (Continue ) C 50S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

54 (Continue) Cesarean When compare with vaginal birth, a history of cesarean section increases the likelihoo of these averse reprouctive outcomes: infertilty (MC, 2004; Mollison, 2005; Smith, 2006). lthough stuies consistently fin fewer subsequent births to women after cesarean at first birth compare with first vaginal birth, it is not possible to etermine from population-base stuies whether ecrease fertility is associate with cesarean surgery or to confouning factors that both reuce fertility an increase the likelihoo of cesarean section. Evience Grae involuntary infertility (MC, 2004). voluntary infertility (MC, 2004). N*** ectopic pregnancy (MC, 2004; Mollison, 2005). variation specific to cesarean section is implantation within the cesarean scar (Jurkovic, 2003; Maymon, 2004). placenta previa (Getahun, 2006; MC, 2004; Olive, 2005). major maternal morbiity in cases of placenta previa compare with women with placenta previa who have no history of cesarean section (Olive, 2005). Major maternal morbiity efine as severe postpartum hemorrhage, acute renal failure, amission to intensive care, ventilation, shock, isseminate intravascular coagulation, or hysterectomy or other proceures to control bleeing or prevent maternal eath. placenta accreta (MC, 2004). This is associate with high rates of catastrophic an life-threatening outcomes, incluing hysterectomy, severe hemorrhage, an the complications that accompany severe hemorrhage, such as isseminate intravascular coagulation, nee for aitional surgery, an maternal eath (Forna, 2004; Makoha, 2004; Selo-Ojeme, 2005; Silver, 2004). placental abruption (Getahun, 2006; MC, 2004; Tikkanen, 2006). uterine rupture in future pregnancies or labors (MC, 2004). ** When compare with vaginal birth, a history of cesarean section increases the likelihoo of these averse outcomes for babies of future pregnancies: perinatal eath (MC, 2004). ** may increase unexplaine stillbirth at term (ahtiyar, 2006; MC, 2004). low birth weight an preterm birth (MC, 2004; Seiman, 1994). (Continue ) N* Step 6: Scientific Evience Goer, Leslie, & Romano 51S

55 (Continue) Cesarean Evience Grae congenital malformation (MC, 2004). C** central nervous system injury (MC, 2004). N*** Elective cesarean section offers minimal protective benefit against moerate to severe urinary incontinence in the short term an none at all in the long term (Chin, 2006; Groutz 2004; MC, 2004). The excess percentage of women experiencing urinary incontinence at 1 year is 6% or less. Elective cesarean section offers minimal protective benefit against anal incontinence in the short term an none at all in the long term (MC, 2004). The excess percentage of women experiencing anal incontinence at 1 year is about 3%. The cesarean section rate can safely be 7% or less in a mixe parity, low-risk population (Goul, 2004; Johnson, 2005; MC, 2004). The cesarean section rate can safely be 12% or less in a mixe parity, mixe-risk population (MC, 2004). The cesarean section rate can safely be 11% or less in a low-risk, nulliparous population (Johnson, 2005; MC, 2004). ¼ goo, ¼ fair, C ¼ weak, N ¼ not applicable Quality ¼ aggregate of quality ratings for iniviual stuies Quantity ¼ magnitue of effect, numbers of stuies, an sample size or power Consistency ¼ the extent to which similar finings are reporte using similar an ifferent stuy esigns *only 1 stuy **multiple stuies in a SR ***only 1 stuy in a SR ** REFERENCES Groutz,., Rimon, E., Pele, S., Gol, R., Pauzner, D., Lessing, J.., et al. (2004). Cesarean section: oes it really prevent the evelopment of postpartum stress urinary incontinence? prospective stuy of 363 women one year after their first elivery. Neurourology an Uroynamics, 23(1), 2 6. Maternity Center ssociation. (2004). Harms of cesarean versus vaginal birth: systematic review. In Chilbirth Connection, What every pregnant woman nees to know about cesarean section (booklet; 2n eition 2006, revise; pp ). New York: uthor. lso, retrieve December 17, 2006, from org/article.asp?ck¼10271 National Institutes of Health. (2006, March 26 29). National Institutes of Health State-of-the-Science Conference Statement. Cesarean elivery on maternal request. ethesa, MD: uthor. lso, retrieve December 17, 2006, from /CesareanStatement_Final pf Worl Health Organization [WHO]. (1985). ppropriate technology for birth. Lancet, 2(8452), INCLUDED STUDIES ahtiyar, M. O., Julien, S., Robinson, J. N., Lumey, L., Zybert, P., Copel, J.., et al. (2006). Prior cesarean elivery is not associate with an increase risk of stillbirth in a subsequent pregnancy: nalysis of U.S. perinatal mortality ata, merican Journal of Obstetrics an Gynecology. 195(5), urrows, L. J., Meyn, L.., & Weber,. M. (2004). Maternal morbiity associate with vaginal versus cesarean elivery. Obstetrics & Gynecology, 103(5, Pt. 1), Carter, F.., Frampton, C. M., & Muler, R. T. (2006). Cesarean section an postpartum epression: review of the evience examining the link. Psychosomatic Meicine, 68(2), Chin, H. Y., Chen, M. C., Liu, Y. H., & Wang, K. H. (2006). Postpartum urinary incontinence: comparison of vaginal elivery, elective, an emergent cesarean section. International Urogynecology Journal an Pelvic Floor Dysfunction. 17(6), Declercq, E., Sakala, C., Corry, M. P., pplebaum, S., & Risher, P. (2002). Listening to mothers: Report of the 52S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

56 first national U.S. survey of women s chilbearing experiences. New York: Maternity Center ssociation. Dessole,S.,Cosmi,E.,alata,.,Uras,L.,Caserta,D., Capobianco, G., et al. (2004). cciental fetal lacerations uring cesarean elivery: Experience in an Italian level III university hospital. merican Journal of Obstetrics an Gynecology, 191(5), Fogelson, N. S., Menar, M. K., Hulsey, T., & Ebeling, M. (2005). Neonatal impact of elective repeat cesarean elivery at term: comment on patient choice cesarean elivery. merican Journal of Obstetrics an Gynecology, 192(5), Forna, F., Miles,. M., & Jamieson, D. J. (2004). Emergency peripartum hysterectomy: comparison of cesarean an postpartumhysterectomy. mericanjournal ofobstetrics an Gynecology, 190(5), Gerten, K.., Coonro, D. V., ay, R. C., & Chambliss, L. R. (2005). Cesarean elivery an respiratory istress synrome: Does labor make a ifference? merican Journal of Obstetrics an Gynecology, 193(3,Pt.2), Getahun, D., Oyelese, Y., Salihu, H. M., & nanth, C. V. (2006). Previous cesarean elivery an risks of placenta previa an placental abruption. Obstetrics & Gynecology, 107(4), Goul, J.., Danielsen,., Korst, L. M., Phibbs, R., Chance, K., Main, E., et al. (2004). Cesarean elivery rates an neonatal morbiity in a low-risk population. Obstetrics & Gynecology, 104(1), Groutz,., Rimon, E., Pele, S., Gol, R., Pauzner, D., Lessing, J.., et al. (2004). Cesarean section: oes it really prevent the evelopment of postpartum stress urinary incontinence? prospective stuy of 363 women one year after their first elivery. Neurourology an Uroynamics, 23(1), 2 6. Johnson, K. C., & Daviss,.. (2005). Outcomes of planne home births with certifie professional miwives: Large prospective stuy in North merica. MJ, 330(7505), Juhn, Y. J., Weaver,., Katusic, S., & Yunginger, J. (2005). Moe of elivery at birth an evelopment of asthma: population-base cohort stuy. The Journal of llergy an Clinical Immunology, 116(3), Jurkovic, D., Hillaby, K., Woelfer,., Lawrence,., Salim, R., & Elson, C. J. (2003). First-trimester iagnosis an management of pregnancies implante into the lower uterine segment Cesarean section scar. Ultrasoun in Obstetrics & Gynecology, 21(3), Koroukian, S. M. (2004). Relative risk of postpartum complications in the Ohio Meicai population: Vaginal versus cesarean elivery. Meical Care Research an Review, 61(2), Kwee,., ots, M. L., Visser, G. H., & ruinse, H. W. (2006). Emergency peripartum hysterectomy: prospective stuy in The Netherlans. European Journal of Obstetrics, Gynecology, an Reprouctive iology, 124(2), Latthe, P., Mignini, L., Gray, R., Hills, R., & Khan, K. (2006). Factors preisposing women to chronic pelvic pain: Systematic review. MJ, 332(7544), Laubereau,., Filipiak-Pittroff,., von erg,., Grubl,., Reinhart, Wichmann, H. E., et al. (2004). Caesarean section an gastrointestinal symptoms, atopic ermatitis, an sensitisation uring the first year of life. rchives of Disease in Chilhoo, 89(11), Liu, S., Heaman, M., Joseph, K.S., Liston, R. M., Huang, L., Sauve, R., et al. (2005). Risk of maternal postpartum reamission associate with moe of elivery. Obstetrics & Gynecology, 105(4), Lyell, D. J., Caughey,.., Hu, E., & Daniels, K. (2005). Peritoneal closure at primary cesarean elivery an ahesions. Obstetrics & Gynecology, 106(2), Maitra,., Sherriff,., Strachan, D., & Henerson, J. (2004). Moe of elivery is not associate with asthma or atopy in chilhoo. Clinical an Experimental llergy, 34(9), Makoha, F. W., Felimban, H. M., Fathuien, M.., Roomi, F., & Ghabra, T. (2004). Multiple cesarean section morbiity. International Journal of Gynaecology an Obstetrics, 87(3), Maternity Center ssociation. (2004). Harms of cesarean versus vaginal birth: systematic review. In Chilbirth Connection, What every pregnant woman nees to know about cesarean section (booklet; 2n eition 2006, revise; pp ). New York: uthor. lso, retrieve December 17, 2006, from org/article.asp?ck¼10271 Maymon, R., Halperin, R., Menlovic, S., Schneier, D., Vaknin, Z., Herman,., et al. (2004). Ectopic pregnancies in Caesarean section scars: the 8 year experience of one meical centre. Human Reprouction, 19(2), Mollison, J., Porter, M., Campbell, D., & hattacharya, S. (2005). Primary moe of elivery an subsequent pregnancy. JOG, 112(8), Myers, S.., & ennett, T. L. (2005). Incience of significant ahesions at repeat cesarean section an the relationship to metho of prior peritoneal closure. The Journal of Reprouctive Meicine, 50(9), Negele,K.,Heinrich,J.,orte,M.,erg,.,Schaaf,., Lehmann, I., et al. (2004). Moe of elivery an evelopment of atopic isease uring the first 2 years of life. Peiatric llergy an Immunology, 15(1), Nikolajsen,L.,Sorensen,H.C.,Jensen,T.S.,&Kehlet, H. (2004). Chronic pain following Caesarean section. cta naesthesiologica Scaninavica, 48(1), Olive, E. C., Roberts, C. L., lgert, C. S., & Morris, J. M. (2005). Placenta praevia: Maternal morbiity an place of birth. The ustralian & New Zealan Journal of Obstetrics & Gynaecology, 45(6), Phipps, M. G., Watabe,., Clemons, J. L., Weitzen, S., & Myers, D. L. (2005). Risk factors for blaer injury uring cesarean elivery. Obstetrics & Gynecology, 105(1), Seiman, D. S., Paz, I., Nau,., Dollberg, S., Stevenson, D. K., Gale, R., et al. (1994). re multiple cesarean sections safe? European Journal of Obstetrics, Gynecology, an Reprouctive iology, 57(1), Step 6: Scientific Evience Goer, Leslie, & Romano 53S

57 Selo-Ojeme, D. O., hattacharjee, P., Izuwa-Njoku, N. F., & Kair, R.. (2005). Emergency peripartum hysterectomy in a tertiary Lonon hospital. rchives of Gynecology an Obstetrics, 271(2), Silver, R. (2004). The MFMU cesarean section registry: Maternal morbiity associate with multiple repeat cesarean elivery. merican Journal of Obstetrics an Gynecology, 191(6, Supp. 1), S17. Smith, G. C., Woo,. M., Pell, J. P., & Dobbie, R. (2006). First cesarean birth an subsequent fertility. Fertility an Sterility, 85(1), Tikkanen, M., Nuutila, M., Hiilesmaa, V., Paavonen, J., & Ylikorkala, O. (2006). Prepregnancy risk factors for placental abruption. cta Obstetricia et Gynecologica Scaninavica, 85(1), EXCLUDED STUDIES ailit, J. L., Garrett, J. M., Miller, W. C., McMahon, M. J., & Cefalo, R. D. (2002). Hospital primary cesarean elivery rates an the risk of poor neonatal outcomes. merican Journal of Obstetrics an Gynecology, 187(3), Reason: Stuy compare neonatal outcomes at hospitals with cesarean-section rates lower than expecte, as expecte, an higher than expecte accoring to primary cesarean-section rates calculate for each hospital. Weaknesses inclue: clinically insignificant ifferences between cesarean rates, especially between overall expecte an higher-than-expecte rates (8% vs. 13% vs. 14%); failure to efine asphyxia; clinically insignificant absolute ifference in asphyxia/trauma rates between hospitals at an below preicte cesarean-section rates (1.29% low, 1.26% expecte, absolute ifference 3 per 10,000); an the assumption that care in expecte rate hospitals was optimal. hattacharya, S., Porter, M., Harril, K., Naji,., Mollison, J., van Teijlingen, E., et al. (2006). Fertility an assiste reprouction bsence of conception after caesarean section: Voluntary or involuntary? JOG, 113(3), Reason: Insufficient response rate. Only 60% of women returne the questionnaire: 75% of women having cesareans versus 50% of women having spontaneous vaginal births an instrumental vaginal births. Overall weakness an iscrepancy in rate of return groups creates a high potential for biase results. loom,s.l.,spong,c.y.,weiner,s.j.,lanon,m.., Rouse, D. J., Varner, M. W., et al. (2005). Complications of anesthesia for cesarean elivery. Obstetrics & Gynecology, 106(2), Reason: Stuy not relevant. uchsbaum, G. M., Duecy, E. E., Kerr, L.., Huang, L-S., & Guzick, D. (2005). Urinary incontinence in nulliparous women an their parous sisters. Obstetrics & Gynecology, 106(6), Reason: Not applicable. No cesarean comparison group. Carvalho,., Riley, E., Cohen, S. E., Gambling, D., Palmer, C., Huffnagle, H. J., et al. (2005). Singleose, sustaine-release epiural morphine in the management of postoperative pain after elective cesarean elivery: Results of a multicenter ranomize controlle stuy. nesthesia an nalgesia, 100(4), Reason: Stuy not relevant. Chisaka, H., Utsunomiya, H., Okamura, K., & Yaegashi, N. (2004). Pulmonary thromboembolism following gynecologic surgery an cesarean section. International Journal of Gynaecology an Obstetrics, 84(1), Reason: Stuy not applicable. Debley, J. S., Smith, J. M., Reing, G. J., & Critchlow, C. W. (2005). Chilhoo asthma hospitalization risk after cesarean elivery in former term an premature infants. nnals of llergy, sthma & Immunology, 94(2), Reason: Stuy not relevant. Eggesbo, M., otten, G., Stigum, H., Samuelsen, S. O., runekreef,., & Magnus, P. (2005). Cesarean elivery an cow milk allergy/intolerance. llergy, 60(9), Reason: Unerpowere to etect ifferences between groups. Investigators state that cow milk allergy/intolerance is more common in cesarean espite confience interval that crosses 1. Text iffers from table ata. Hager, R. M., Daltveit,. K., Hofoss, D., Nilsen, S. T., Kolaas, T., Oian, P., et al. (2004). Complications of cesarean eliveries: rates an risk factors. merican Journal of Obstetrics an Gynecology, 190(2), Reason: Stuy not applicable. Stuy has no comparison ata with vaginal birth. Jacobsen,. F., Drolsum,., Klow, N. E., Dahl, G. F., Qvigsta, E., & Sanset, P. M. (2004). Deep vein thrombosis after elective cesarean section. Thrombosis Research, 113(5), Reason: Stuy not applicable. Kabir,.., Steinmann, W. C., Myers, L., Khan, M. M., Herrera, E.., Yu, S., et al. (2004). Unnecessary cesarean elivery in Louisiana: n analysis of birth certificate ata. merican Journal of Obstetrics an Gynecology, 190(1), 10 19; iscussion 3. Reason: Stuy looks at changes in cesarean rate with respect to inications an risk factors in Louisiana from 1993 to 2000 an conclues that 17% of primary an 43% of repeat cesarean sections were potentially unnecessary. However, inclue stuies are more relevant to the purpose of establishing that the cesarean rate can be reuce without compromising outcomes in that they show that low cesarean rates o not increase averse outcomes. This stuy is also not useful for making a statement about the percentage of cesareans that may be unnecessary because of rapily changing practice patterns. For example, the VC rate has ecline precipitously since Mahoney, S. F., & Malcoe, L. H. (2005). Cesarean elivery in Native merican women: re low rates explaine by practices common to the Inian health service? irth, 32(3), Reason: Poorly esigne. Stuy oes not report neonatal outcomes or compare them to a similar population with higher cesarean rates. There is no means to evaluate the safety of having a low cesarean rate. 54S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

58 McKenna, D. S., Ester, J.., & Fischer, J. R. (2003). Elective cesarean elivery for women with a previous anal sphincter rupture. merican Journal of Obstetrics an Gynecology, 189(5), Reason: Poorly esigne. Stuy is a risk-benefit analysis of elective cesarean in women with anal sphincter laceration at first birth. Weaknesses inclue the following: Defines anal incontinence as leakage of gas as well as fecal incontinence or urgency. Most cases of incontinence are confine to gas leakage, which means weighing the averse effects of major surgery against the benefits of preventing flatus. The investigators calculate that, for every 1,880 cases of anal incontinence prevente, one woman will ie. In the Year 2000, 12 aitional women woul ie to prevent 22,107 cases of anal incontinence. ssumes elective cesarean prevents all cases of anal incontinence an, at the same time, cites a stuy in the iscussion in which 3% of women having elective cesarean ha anal incontinence at 10 months postpartum. Calculates a 5.3% incience of anal injury in the first pregnancy without accounting for the contribution of moifiable factors such as meian episiotomy or vaginal instrumental birth. Fails to inclue consieration of many excess risks of cesarean surgery an repeat cesarean surgery from the comparison with vaginal birth, incluing infertility, ectopic pregnancy, uterine rupture, placental abruption, or any excess perinatal morbiity or mortality. McKinnie, V., Swift, S. E., Wang, W., Wooman, P., O oyle,., Kahn, M., et al. (2005). The effect of pregnancy an moe of elivery on the prevalence of urinary an fecal incontinence. merican Journal of Obstetrics an Gynecology, 193(2), ; iscussion Reason: Poorly esigne. No information on episiotomy, which, because this is a U.S. stuy, woul be meian episiotomy an, therefore, an important confouning factor for anal sphincter injury an weakness. No power calculation. Not population base. No consieration of time since most recent birth. Incontinence symptoms iminish markely in prevalence an severity in the first 6 months after chilbirth. National Collaborating Centre for Women s an Chilren s Health. (2004, pril). Caesarean section. Clinical guieline. Lonon: RCOG Press. lso, retrieve December 17, 2006, from CG013fullguieline.pf Reason: Have better quality research. The Maternity Center ssociation (2004) SR reviews many of the same stuies an aresses a broaer range of issues of interest to women an clinicians in making informe ecisions, an it exclues stuies for reasons that this SR fails to consier. For example, this review accepts Cochrane Database systematic reviews with an unacceptably high egree of protocol violations (crossovers between treatment groups), while the Maternity Center ssociation (2004) SR oes not. Pollack, J., Norenstam, J., rismar, S., Lopez,., ltman, D., & Zetterstrom, J. (2004). nal incontinence after vaginal elivery: five-year prospective cohort stuy. Obstetrics & Gynecology, 104(6), Reason: Not applicable. No cesarean comparison group. Press, J., Klein, M. C., & von Daelszen, P. (2006). Moe of elivery an pelvic floor ysfunction: systematic review of the literature on urinary an fecal incontinence an sexual ysfunction by moe of elivery. In Mescape. Retrieve December 16, 2006, from Reason: Poorly written. Stuy fails to reveal methoology. Puza, S., Roth, N., Macones, G.., Mennuti, M. T., & Morgan, M.. (1998). Does cesarean section ecrease the incience of major birth trauma? Journal of Perinatology, 18(1), Reason: Poorly esigne. This before/after stuy looks at whether the increase in cesarean rates resulte in ecrease neonatal trauma without investigating other factors that might have change along with change in cesarean rates. Rouse, D. J., Lanon, M., Leveno, K. J., Leinecker, S., Varner, M., Caritis, S., et al. (2004). The Maternal- Fetal Meicine Units cesarean registry: Chorioamnionitis at term an its uration-relationship to outcomes. merican Journal of Obstetrics an Gynecology, 191(1), Reason: Have better-quality research. Investigators conclue that chorioamnionitis increase maternal an neonatal morbiity after cesarean, but efine chorioamnionitis as intrapartum fever without accounting for epiural use. Rouse, D. J., Leinecker, S., Lanon, M., loom, S., Varner, M., Moawa,., et al. (2005). The MFMU Cesarean Registry: Uterine atony after primary cesarean elivery. merican Journal of Obstetrics an Gynecology, 193(3, Pt. 2), Reason: Not applicable. No vaginal birth comparison group. Seffah, J. D. (2005). Re-laparotomy after Cesarean section. International Journal of Gynaecology an Obstetrics, 88(3), Reason: Stuy not applicable. Carrie out in a resource-poor country (Ghana). Sule, S. T., & Nwasor, E. O. (2005). Factors affecting bloo loss at cesarean section. International Journal of Gynaecology an Obstetrics, 88(2), Reason: Stuy not applicable. Carrie out in a resource-poor country (Nigeria). Taylor, L. K., Simpson, J. M., Roberts, C. L., Olive, E. C., & Henerson-Smart, D. J. (2005). Risk of complications in a secon pregnancy following caesarean section in the first pregnancy: population-base stuy. The Meical Journal of ustralia, 183(10), Reason: Stuy not relevant. There is no statistical analysis of outcomes at secon birth of all women having cesarean at first birth versus all women having first vaginal birth. Stuy compares maternal an neonatal outcomes of: all women having initial cesarean followe by planne VC with all women having first vaginal birth an laboring in secon pregnancy; an all women having initial cesarean followe by planne repeat cesarean section with all women Step 6: Scientific Evience Goer, Leslie, & Romano 55S

59 having first vaginal birth an planne cesarean section at secon birth. Tran, T. S., Jamulitrat, S., Chongsuvivatwong, V., & Geater,. (2000). Risk factors for postcesarean surgical site infection. Obstetrics & Gynecology, 95(3), Reason: Stuy not applicable. Carrie out in a resource-poor country (Viet Nam). Vermillion, S. T., Lamoutte, C., Soper, D. E., & Vereja,. (2000). Woun infection after cesarean: Effect of subcutaneous tissue thickness. Obstetrics & Gynecology, 95(6, Pt. 1), Reason: Have more recent research Viktrup, L., & Lose, G. (2001). The risk of stress incontinence 5 years after first elivery. merican Journal of Obstetrics an Gynecology, 185(1), Reason: Cannot etermine relationship between obstetric management an incontinence. Waterstone, M., ewley, S., & Wolfe, C. (2001). Incience an preictors of severe obstetric morbiity: Case-control stuy. MJ, 322(7294), ; iscussion Reason: Have more recent research. Zanaro, V., Simbi,. K., Savio, V., Micaglio, M., & Trevisanuto, D. (2004). Neonatal resuscitation by laryngeal mask airway after elective cesarean section. Fetal Diagnosis an Therapy, 19(3), Reason: Poorly esigne. Stuy examines nee for neonatal resuscitation after elective cesarean, but efines elective cesarean as being carrie out before labor, which means the cesareans may not all have been truly elective, that is, without meical inication. Fogelson (2005), an inclue stuy (see p. 53S), reporte on respiratory outcomes after truly elective cesareans, that is, women unergoing uncomplicate, term, elective repeat cesareans. Step 6: Limits interventions, as follows: VC rate of 60% or more, with a goal of 75% or more Several ecaes of research into the question of planne VC versus elective repeat cesarean have prouce hunres of stuies involving tens of thousans of women an a large boy of knowlege on the subject. Nonetheless, many of the prominent stuies are beset by serious problems that make it ifficult to gauge the true comparative risks of planne vaginal birth versus elective repeat cesarean problems that, moreover, ten to bias the picture in favor of repeat cesarean. The problems inclue the following: Planning status cannot be etermine accurately in population-base stuies large enough to etect ifferences between groups for rare, but severe, averse outcomes. Without knowing whether repeat cesareans were truly elective an VC women an their babies were healthy at labor onset, we cannot have confience that outcomes are attributable to birth route. Even the sole prospective stuy (Lanon et al., 2004) suffers from this efect (Goer, 2005). Most stuies comparing the two birth routes report only on outcomes occurring in the perinatal perio. They o not take into account the escalating risks of accumulating cesarean surgeries when rawing conclusions about the balance between the potential harms of planne vaginal birth versus planne repeat surgery. ecause of the increase risk of uterine scar rupture uring VC labor an the increase cesarean complication rate in unplanne cesareans, there may be equipoise or near equipoise between the two alternatives provie that women limit family size to two chilren. However, sizeable percentages of women will go on to have more pregnancies, intene or unintene. ccoring to the 2002 U.S. National Survey of Family Growth, 36% of women age 40 to 44 years have more than two chilren (U.S. Department of Health an Human Services, 2005). That percentage will be much higher among populations where large families are the norm. The increasing risk of ense surgical ahesions an the resultant potential for experiencing chronic pain, injuries uring future surgeries, an bowel obstruction is also missing from the equation. Scar rupture rates an vaginal birth rates in women planning VC epen heavily on care provier philosophy an policies regaring VC. Moifiable factors such as preset limits on labor uration, inucing an augmenting labor, what agents an osages are use for those proceures, an uterine suture technique an material at the initial surgery have profoun effects, as the wie ranges reporte for these outcomes in the various stuies attest. When the long-term view is taken, it becomes clear that maximizing VC rates among women who choose VC an minimizing the risk of scar rupture uring planne vaginal births will prouce the best maternal-chil health an reprouctive outcomes. This is because those goals reuce exposure to the potential harms of repeate cesarean surgeries, of VC labors, an to the excess morbiity attenant on 56S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

60 unplanne cesarean sections. It also bears pointing out that the policies an proceures espouse in the Ten Steps of Mother-Frienly Care will best promote safer VC an higher VC rates. In furtherance of those twin goals, clinicians have the obligation to provie women with complete, unbiase, an evience-base information on the comparative benefits an harms of planne vaginal birth versus planne repeat cesarean so that they may make an informe ecision. Nonetheless, regarless of the care provier s opinion of the relative safety of the two options in any iniviual case, the choice rests solely in the hans of the pregnant woman, unless she chooses to cee her right to her care provier. VC enial, or instituting restrictions that amount to VC enial, constitutes coercion in that it forces women to consent to major surgery in orer to obtain care. The merican College of Obstetricians an Gynecologists (2000) guarantees women freeom from this violation of their rights, as the following passage makes clear: Once a patient has been informe of the material risks an benefits involve with a treatment, test, or proceure, that patient has the right to exercise full autonomy in eciing whether to unergo the treatment, test, or proceure or whether to make a choice among a variety of treatments, tests, or proceures. In the exercise of that autonomy, the informe patient also has the right to refuse to unergo any of these treatments, tests, or proceures.... Performing an operative proceure on a patient without the patient s permission can constitute battery uner common law. In most circumstances this is a criminal act.... Such a refusal [of consent] may be base on religious beliefs, personal preference, or comfort. (pp ) Note that, although cesarean section is a proceure (something that requires a care provier to take positive action for it to occur), planne vaginal birth is not because labor is the inevitable en of pregnancy. Note too that the right to refuse is not preicate on the woman having what the clinician consiers an acceptable reason. Some have claime that the weaknesses of the stuies cannot be overcome without a ranomize controlle trial, an, inee, one is currently unerway in ustralia. a s will be seen below, however, those weaknesses o not prevent arriving at an aequate unerstaning of the comparative benefits an harms of planne vaginal birth versus planne cesarean surgery, an unerstaning that is, moreover, unlikely to be improve by such a trial for the reasons liste above. VC Compare with one cesarean birth, accumulating cesarean surgeries imposes increasing risks of (see pp. 48S 56S for risks of an iniviual cesarean): ahesions (Makoha, 2004; Seiman, 1994): Known risks of ahesions inclue chronic pain, the possibility of causing intestinal obstruction, an increase risk of injury uring subsequent surgeries. Evience Grae cesarean scar ectopic pregnancy (Jurkovic, 2003; Maymon, 2004). placenta previa (Getahun, 2006; Makoha, 2004; MC, 2004). placenta accreta (Silver, 2004): Placenta accreta is associate with high rates of catastrophic an life-threatening outcomes, incluing hysterectomy, severe hemorrhage an the complications that accompany severe hemorrhage such as isseminate intravascular coagulation, nee for aitional surgery, an maternal eath (Forna, 2004; Makoha, 2004; Selo-Ojeme, 2005; Silver, 2004). (Continue ) Step 6: Scientific Evience Goer, Leslie, & Romano 57S

61 (Continue) VC placenta previa/accreta b (Chattopahyay, 1993; Makoha, 2004; Miller, 1997; Silver, 2004; To, 1995). Evience Grae hemorrhage requiring transfusion c (Makoha, 2004; Silver, 2004). hysterectomy (Kwee, 2006; Makoha, 2004; Selo-Ojeme, 2005; Silver, 2004). blaer injury (Makoha, 2004; Phipps, 2005). neonatal respiratory complications (Seiman, 1994). C C N* Compare with planne vaginal birth, elective repeat cesarean section increases the risk of: maternal infection (Guise, 2003). C ** hemorrhage requiring transfusion c (Guise, 2003; Macones, 2005; Mozurkewich, Hutton 2000). hysterectomy (Guise, 2003; Mozurkewich, 2000). (One SR reporte fewer hysterectomies; the other reporte similar rates.) neonatal respiratory complications (Loebel, 2004). C N* Vaginal birth appears to be protective against symptomatic scar rupture (Lieberman, 2001; Macones, 2005; Smith, 2004). The incience of symptomatic uterine scar rupture can be 4 per 1,000 planne vaginal births or fewer e (Gonen 2006; Guise, 2003; Lanon et al., 2004; Lieberman, 2004; Loebel, 2004; McMahon, 1996; Mozurkewich, 2000; Smith, 2004). Planne repeat cesarean oes not eliminate the possibility of symptomatic uterine scar rupture (Lyon-Rochelle, 2001; Mozurkewich, 2000). Systematic reviews that calculate absolute excess risk (the arithmetic ifference between the two rates) of symptomatic uterine scar rupture with planne VC compare with planne repeat cesarean report values of 2.3 an 2.7 per 1,000 (Guise, 2003; Mozurkewich, 2000). This means that elective cesareans woul be neee to prevent one scar rupture (number neee to treat). The perinatal mortality rate associate with symptomatic uterine scar rupture uring VC labor is extremely low: (Continue ) 58S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

62 (Continue) VC The perinatal mortality rate associate with symptomatic uterine scar rupture uring planne vaginal birth ranges from 1.5 to 4.0 per 10,000 VC labors (Guise, 2003; Lanon et al., 2004; Lyon-Rochelle, 2001; Mozurkewich, 2000; Smith 2002). The excess risk of perinatal eath associate with symptomatic uterine scar rupture compare with planne cesarean section ranges from 1.4 to 2.6 per 10,000 planne VCs (Guise, 2004; Lanon et al., 2004). To put this number into perspective, the excess risk of losing the pregnancy associate with having mi-trimester amniocentesis is 60 per 10,000 (Sees, 2004). This means from 3,846 to 7,142 elective cesareans woul be neee to prevent one perinatal eath. Conclusions in the two stuies examining the issue iffer on whether a ecision-to-incision interval of less than 20 minutes improves outcomes in cases of symptomatic uterine scar rupture (Guise, 2003). The stuy fining that it i inclue cases in which the infant require resuscitation but sustaine no morbiity. If these cases are remove from consieration, only one case of asphyxia remains among the babies with later emergent elivery. Moifiable factors may increase the risk of symptomatic uterine scar rupture. These inclue: inuction of labor with oxytocin (Delaney, 2003; Guise, 2003; Lanon et al., 2004; Lieberman, 2001; Locatelli, 2004; Lyon-Rochelle, 2001; Macones, 2005; Smith, 2004). inuction of labor with PGE2 (Delaney, 2003; Guise, 2003; Locatelli, 2004; Lyon-Rochelle, 2001; Macones 2005; Smith, 2004). inuction of labor with misoprostol (Lieberman, 2001; Plaut, 1999; Wing, 1998). augmentation of labor (Gonen, 2006; Lanon et al., 2004; Macones, 2005; Lieberman, 2001). Evience Grae possibly single-layer uterine closure h (ujol, 2002; Durnwal, 2003). verse outcomes in planne vaginal births occur mostly in women having cesarean sections (Lanon et al., 2004; Loebel, 2004; McMahon, 1996; Phipps, 2005). This argues for policies that maximize likelihoo of vaginal birth. Three out of four women or more in an unselecte population who plan VC shoul have a vaginal birth. This implies that VC rates lower than 70% are ue to moifiable factors. Many stuies an systematic reviews report VC rates aroun 75% in an unselecte population, an rates as high as 87% are reporte (Gonen, 2006; Guise, 2003; Lanon et al., 2004; Lieberman, 2004; Locatelli, 2004; Loebel, 2004; Macones, 2005; Smith, 2002). Rates of 95% have been reporte in women with optimal profiles for VC (Guise, 2003). N to reporting a range of rates N to reporting a range of rates C C f C f g C i N to reporting a range of rates N to reporting a rate N to reporting a rate (Continue ) Step 6: Scientific Evience Goer, Leslie, & Romano 59S

63 (Continue) VC Rates as high as 81% have been reporte among women with no prior vaginal birth (Lieberman, 2004). Even when maternal history an obstetric factors are suboptimal for VC, the chance of VC can be at least 50/50 (Guise, 2003; Lanon, 2004; Macones, 2005; Rosen, 1990). Evience Grae Inucing labor appears to reuce the likelihoo of vaginal birth (Delaney, C 2003; Guise, 2003; Lanon, 2004; Locatelli, 2004). j N to reporting a rate N to reporting a rate ¼ goo, ¼ fair, C ¼ weak, N ¼ not applicable Quality ¼ aggregate of quality ratings for iniviual stuies Quantity ¼ magnitue of effect, numbers of stuies, an sample size or power Consistency ¼ the extent to which similar finings are reporte using similar an ifferent stuy esigns *only 1 stuy **multiple stuies in a SR ***only 1 stuy in a SR a The ustralian trial is being proteste by ustralian grassroots normal birth avocates who question the ethics of assigning healthy women to major abominal surgery when so little new knowlege can be gaine. b The authors of a case series on cesarean scar ectopic pregnancies theorize that placenta previa/accreta results when a cesarean scar implantation evelops into an intrauterine pregnancy (Jurkovic, 2003). c Nee for transfusion was use rather than hemorrhage because it is a more objective measure of bloo loss. In aition, efinitions of hemorrhage vary between vaginal birth an surgical elivery. The usual efinition of hemorrhage at vaginal birth is 500 ml, whereas for surgery it is 1,000 ml. Moreover, while bloo loss is har to measure accurately in either case, it is especially so at vaginal birth. Surgical injury at repeat cesarean is more common because of the presence of ahesions. e Stuies report higher scar rupture rates, but the fact that rates this low are reporte in large, unselecte VC populations inicates that substantially higher rates are almost certainly ue to moifiable factors. f Inconsistencies can probably be explaine by variations in protocol an patient selection (Locatelli, 2004; Macones, 2005). For example, one stuy reporte an increase in scar rupture with the combination of inuction with oxytocin an PGE2 but not with either agent use separately (Macones, 2005). g Inconsistencies may be explaine by variations in oxytocin augmentation protocols. h One stuy foun a significant increase with single-layer closure while another i not. The trial that i not raise the issue of ifferences in suture material an technique between the two stuies possibly affecting scar strength (Durnwal, 2003). No systematic reviews coul be foun aressing the issue of material an technique an scar strength in subsequent VC labors. Until this controversy is settle, a conservative approach woul ictate using oublelayer closure because many stuies preating the use of single-layer closure report symptomatic scar rupture rates less than 5 per 1,000. i Inconsistencies may be explaine by variations in suture material an technique. j Only one stuy reporting this ajuste for the fact that inications for labor inuction might also increase the likelihoo of cesarean section (Delaney, 2003). REFERENCES mericancollege of ObstetriciansanGynecologists.(2000, June). Informe refusal. Committee Opinion No Delaney, T., & Young, D. C. (2003). Spontaneous versus inuce labor after a previous cesarean elivery. Obstetrics an Gynecology, 102(1), Durnwal, C., & Mercer,. (2003). Uterine rupture, perioperative an perinatal morbiity after single-layer an ouble-layer closure at cesarean elivery. merican Journal of Obstetrics an Gynecology, 189(4), Goer, H. (2005). When research is flawe: Is planne VC safe? Retrieve December 18, 2006, from Jurkovic, D., Hillaby, K., Woelfer,., Lawrence,., Salim, R., & Elson, C. J. (2003). First-trimester iagnosis an management of pregnancies implante into the lower uterine segment Cesarean section scar. Ultrasoun in Obstetrics an Gynecology, 21(3), Lanon, M.., Hauth, J. C., Leveno, K. J., Spong, C. Y., Leinecker, S., Varner, M. W., et al. (2004). Maternal an perinatal outcomes associate with a trial of labor after prior cesarean elivery. The New Englan Journal of Meicine, 351(25), Locatelli,., Regalia,. L., Ghiini,., Ciriello, E., iffi,., & Pezzullo, J. C. (2004). Risks of inuction of labour in women with a uterine scar from previous low transverse caesarean section. JOG, 111(12), Macones, G.., Peipert, J., Nelson, D.., Oibo,., Stevens, E. J., Stamilio, D. M., et al. (2005). Maternal complications with vaginal birth after cesarean elivery: a multicenter stuy. merican Journal of Obstetrics an Gynecology, 193(5), S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

64 The Maternity Coalition. irth after caesarean campaign; U.S. Department of Health an Human Services. (2005, December). Fertility, family planning, an reprouctive health of U.S. women: Data from the 2002 National Survey of Family Growth. Vital an Health Statistics, Series 23(25). INCLUDED STUDIES ujol, E., ujol, C., Hamilton, E. F., Harel, F., & Gauthier,R.J.(2002).Theimpactofasingle-layeror ouble-layer closure on uterine rupture. merican Journal of Obstetrics an Gynecology, 186(6), Chattopahyay, S. K., Kharif, H., & Sherbeeni, M. M. (1993). Placenta praevia an accreta after previous caesarean section. European Journal of Obstetrics, Gynecology, an Reprouctive iology, 52(3), Delaney, T., & Young, D. C. (2003). Spontaneous versus inuce labor after a previous cesarean elivery. Obstetrics & Gynecology, 102(1), Durnwal, C., & Mercer,. (2003). Uterine rupture, perioperative an perinatal morbiity after single-layer an ouble-layer closure at cesarean elivery. merican Journal of Obstetrics an Gynecology, 189(4), Forna, F., Miles,. M., & Jamieson, D. J. (2004). Emergency peripartum hysterectomy: comparison of cesarean an postpartumhysterectomy. mericanjournal ofobstetrics an Gynecology, 190(5), Getahun, D., Oyelese, Y., Salihu, H. M., & nanth, C. V. (2006). Previous cesarean elivery an risks of placenta previa an placental abruption. Obstetrics & Gynecology, 107(4), Gonen, R., Nisenblat, V., arak, S., Tamir,., & Ohel, G. (2006). Results of a well-efine protocol for a trial of labor after prior cesarean elivery. Obstetrics & Gynecology, 107(2, Pt. 1), Guise, J. M., McDonagh, M., Hashima, J. N., Kraemer, D., Een, K., erlin, M., et al. (2003, March). Vaginal birth after cesarean (VC) Report/Technology ssessment No. 71. (HRQ Publication No. 03-E018). Rockville, MD: gency for Healthcare Research an Quality. Guise, J. M., McDonagh, M. S., Osterweil, P., Nygren, P., Chan,. K., & Helfan, M. (2004). Systematic review of the incience an consequences of uterine rupture in women with previous caesarean section. MJ, 329(7456), Jurkovic, D., Hillaby, K., Woelfer,., Lawrence,., Salim, R., & Elson, C. J. (2003). First-trimester iagnosis an management of pregnancies implante into the lower uterine segment Cesarean section scar. Ultrasoun in Obstetrics an Gynecology, 21(3), Kwee,., ots, M. L., Visser, G. H., & ruinse, H. W. (2006). Emergency peripartum hysterectomy: prospective stuy in The Netherlans. European Journal of Obstetrics, Gynecology, an Reprouctive iology, 124(2), Lanon, M. (2004). The MFMU cesarean section registry: Factors affecting the success of trial of labor following prior cesarean elivery. merican Journal of Obstetrics an Gynecology, 191(6, Supp. 1), S17. Lanon, M.., Hauth, J. C., Leveno, K. J., Spong, C. Y., Leinecker, S., Varner, M. W., et al. (2004). Maternal an perinatal outcomes associate with a trial of labor after prior cesarean elivery. The New Englan Journal of Meicine, 351(25), Lieberman, E. (2001). Risk factors for uterine rupture uring a trial of labor after cesarean. Clinical Obstetrics an Gynecology, 44(3), Lieberman, E., Ernst, E. K., Rooks, J. P., Stapleton, S., & Flamm,. (2004). Results of the national stuy of vaginal birth after cesarean in birth centers. Obstetrics & Gynecology, 104(5, Pt. 1), Locatelli,., Regalia,. L., Ghiini,., Ciriello, E., iffi,., & Pezzullo, J. C. (2004). Risks of inuction of labour in women with a uterine scar from previous low transverse caesarean section. JOG, 111(12), Loebel, G., Zelop, C. M., Egan, J. F., & Wax. J. (2004). Maternal an neonatal morbiity after elective repeat Cesarean elivery versus a trial of labor after previous Cesarean elivery in a community teaching hospital. Journal of Maternal-Fetal an Neonatal Meicine, 15(4), Lyon-Rochelle, M., Holt, V. L., Easterling, T. R., & Martin, D. P. (2001). Risk of uterine rupture uring labor among women with a prior cesarean elivery. The New Englan Journal of Meicine, 345(1), 3 8. Macones, G.., Peipert, J., Nelson, D.., Oibo,., Stevens, E., Stamilio, D., et al. (2005). Maternal complications with vaginal birth after cesarean elivery: multicenter stuy. merican Journal of Obstetrics an Gynecology, 193(5), Makoha, F. W., Felimban, H. M., Fathuien, M.., Roomi, F., & Ghabra, T. (2004). Multiple cesarean section morbiity. International Journal of Gynaecology an Obstetrics, 87(3), Maternity Center ssociation. (2004). Harms of cesarean versus vaginal birth: systematic review. In Chilbirth Connection, What every pregnant woman nees to know about cesarean section (booklet; 2n eition 2006, revise; pp ). New York: uthor. lso, retrieve December 17, 2006, from org/article.asp?ck¼10271 Maymon, R., Halperin, R., Menlovic, S., Schneier, D., Vaknin, Z., Herman,., et al. (2004). Ectopic pregnancies in Caesarean section scars: The 8 year experience of one meical centre. Human Reprouction, 19(2), McMahon, M. J., Luther, E. R., owes, W.., Jr., & Olsahan,. F. (1996). Comparison of a trial of labor with an elective secon cesarean section. The New Englan Journal of Meicine, 335(10), Miller, D.., Chollet, J.., & Goowin, T. M. (1997). Clinical risk factors for placenta previa-placenta accreta. merican Journal of Obstetrics an Gynecology, 177(1), Mozurkewich, E. L., & Hutton, E. K. (2000). Elective repeat cesarean elivery versus trial of labor: metaanalysis of the literature from 1989 to merican Step 6: Scientific Evience Goer, Leslie, & Romano 61S

65 Journal of Obstetrics an Gynecology, 183(5), Phipps, M. G., Watabe,., Clemons, J. L., Weitzen, S., & Myers, D. L. (2005). Risk factors for blaer injury uring cesarean elivery. Obstetrics & Gynecology, 105(1), Plaut, M. M., Schwartz, M. L., & Lubarsky, S. L. (1999). Uterine rupture associate with the use of misoprostol in the gravi patient with a previous cesarean section. merican Journal of Obstetrics an Gynecology, 180(6, Pt. 1), Rosen, M. G., & Dickinson, J. C. (1990). Vaginal birth after cesarean: meta-analysis of inicators for success. Obstetrics & Gynecology, 76(5, Pt. 1), Sees, J. W. (2004). Diagnostic mi trimester amniocentesis: How safe? merican Journal of Obstetrics an Gynecology, 191(2), Seiman, D. S., Paz, I., Nau,., Dollberg, S., Stevenson, D. K., Gale, R., et al. (1994). re multiple cesarean sections safe? European Journal of Obstetrics, Gynecology, an Reprouctive iology, 57(1), Selo-Ojeme, D. O., hattacharjee, P., Izuwa-Njoku, N. F., & Kair, R.. (2005). Emergency peripartum hysterectomy in a tertiary Lonon hospital. rchives of Gynecology an Obstetrics, 271(2), Silver, R. (2004). The MFMU cesarean section registry: Maternal morbiity associate with multiple repeat cesarean elivery. merican Journal of Obstetrics an Gynecology, 191(6, Supp. 1), S17. Smith, G. C., Pell, J. P., Cameron,. D., & Dobbie, R. (2002). Risk of perinatal eath associate with labor after previous cesarean elivery in uncomplicate term pregnancies. The Journal of the merican Meical ssociation, 287(20), Smith, G. C., Pell, J. P., Pasupathy, D., & Dobbie, R. (2004). Factors preisposing to perinatal eath relate to uterine rupture uring attempte vaginal birth after caesarean section: Retrospective cohort stuy. MJ, 329(7462), 375. To, W. W., & Leung, W. C. (1995). Placenta previa an previous cesarean section. International Journal of Gynaecology an Obstetrics, 51(1), Wing, D.., Lovett, K., & Paul, R. H. (1998). Disruption of prior uterine incision following misoprostol for labor inuction in women with previous cesarean elivery. Obstetrics & Gynecology, 91(5, Pt. 2), EXCLUDED STUDIES lanchette, H., lanchette, M., McCabe, J., & Vincent, S. (2001). Is vaginal birth after cesarean safe? Experience at a community hospital. merican Journal of Obstetrics an Gynecology, 184(7), ; iscussion Reason: Stuy not applicable. The high uterine rupture rate (1.6%) implies iatrogenic factors involve. Inuction metho not escribe, but misoprostol was use in a scar rupture that ene in neonatal eath. oulvain, M., Fraser, W. D., risson-carroll, G., Faron, G., & Wollast, E. (1997). Trial of labour after caesarean section in sub-saharan frica: meta-analysis. ritish Journal of Obstetrics an Gynaecology, 104(12), Reason: Stuy not applicable. Carrie out in a resource-poor region. Chapman, S. J., Owen, J., & Hauth, J. C. (1997). Oneversus two-layer closure of a low transverse cesarean: The next pregnancy. Obstetrics & Gynecology, 89(1), Reason: Stuy lacks statistical strength. Investigators compare scar rupture rates in VC labor in women ranomly assigne to single-layer or oublelayer uterine suturing in immeiately preceing primary cesarean-section birth. They only ha 83 in the single-layer an 81 in the ouble-layer groups. If the absolute increase in scar rupture rate is a few percent, which it appears to be, base on larger stuies, this is still an important ifference, but this stuy is unerpowere to etect it. Chelmow, D., & Laros, R.K., Jr. (1992). Maternal an neonatal outcomes after oxytocin augmentation in patients unergoing a trial of labor after prior cesarean elivery. Obstetrics & Gynecology, 80(6), Reason: Stuy lacks statistical strength. Stuy evaluate safety an effectiveness of oxytocin augmentation for ysfunctional labor in women with prior cesarean, but there were only 62 women in the group, not enough to etect a moest, but important, ifference in scar rupture rates. Connolly, G., Razak,., Conroy, R., Harrison, R., & McKenna, P. (2001). five year review of scar ehiscence in the Rotuna Hospital, Dublin. Irish Meical Journal, 94(6), Reason: Stuy exclue from Guise (2003) SR, an inclue stuy here. Do, J., Crowther, C.., Huertas, E., Guise, J. M., & Horey, D. (2004). Planne elective repeat caesarean section versus planne vaginal birth for women with a previous caesarean birth (Review). Cochrane Database of Systematic Reviews, (4), CD Reason: Not applicable. Enkin, M. W., & Wilkinson, C. (2000). Single versus two layer suturing for closing the uterine incision at caesarean section. Cochrane Database of Systematic Reviews, (2), CD Reason: Not relevant. Has no ata on effect in VC labors. Goetzl, L., Shipp, T. D., Cohen,., Zelop, C. M., Repke, J. T., & Lieberman, E. (2001). Oxytocin ose an the risk of uterine rupture in trial of labor after cesarean. Obstetrics & Gynecology, 97(3), Reason: Stuy exclue from Guise (2003) SR, an inclue stuy here. Guise, J. M., erlin, M., McDonagh, M., Osterweil, P., Chan,., & Helfan, M. (2004). Safety of vaginal birth after cesarean: systematic review. Obstetrics & Gynecology, 103(3), Reason: Stuy base on ata from Guise (2003) SR. Hashima, J. N., Een, K.., Osterweil, P., Nygren, P., & Guise, J. M. (2004). Preicting vaginal birth after cesarean elivery: review of prognostic factors an screening tools. merican Journal of Obstetrics an Gynecology, 190(2), Reason: Stuy base on ata from Guise (2003) SR. Henler, I., & ujol, E. (2004). Effect of prior vaginal elivery or prior vaginal birth after cesarean elivery on obstetric outcomes in women unergoing trial of 62S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

66 labor. Obstetrics & Gynecology, 104(2), Reason: Failure to fin a significant ifference in scar rupture rate with prior vaginal birth or VC coul be a Type II error. Rates are 1.5% with no prior vaginal birth, 0.5% with prior vaginal birth before the cesarean, an 0.3% with prior VC, but only 198 an 321 women, respectively, fell into these categories. Investigators note a higher ehiscence rate with prior VC because 5/24 women ha a ehiscence at repeat cesarean or emergency postpartum laparotomy. However, we have no reason to believe that ehiscence occurre at the same rate in the 297 women who ha uneventful VCs. McDonagh, M. S., Osterweil, P., & Guise, J. M. (2005). The benefits an risks of inucing labour in patients with prior caesarean elivery: systematic review. JOG, 112(8), Reason: Poorly esigne. SR inclues 2 RCTs an 12 observational stuies. Problems inclue the following: Neither RCT evaluates usual inuction protocols. One is a trial of mifepristone an the other aministers PGE2 once weekly. These two trials are the only stuies of oxytocin that report ata on inuction separate from augmentation. Starting labor versus augmenting a labor alreay in progress is likely to have ifferent effects on both repeat cesarean rates an scar rupture rates. One stuy is of misoprostol, an agent not recommene for inucing women with uterine scars because of its strong association with scar rupture. This trial is inclue in a meta-analysis of scar rupture. McNally, O. M., & Turner, M. J. (1999). Inuction of labour after 1 previous Caesarean section. The ustralian & New Zealan Journal of Obstetrics & Gynaecology, 39(4), Reason: Stuy lacks statistical strength. Stuy evaluate safety an effectiveness of oxytocin inuction in women with prior cesarean, but only inclue 103 women, not enough to etect a moest, but important, ifference in scar rupture rates. Pare, E., Quinones, J. N., & Macones, G.. (2006). Vaginal birth after caesarean section versus elective repeat caesarean section: ssessment of maternal ownstream health outcomes. JOG, 113(1), Reason: Not applicable. Stuy evelops a ecision moel. Ravasia, D. J., Woo, S. L., & Pollar, J. K. (2000). Uterine rupture uring inuce trial of labor among women with previous cesarean elivery. merican Journal of Obstetrics an Gynecology, 183(5), Reason: Stuy exclue from Guise (2003) SR. Richarson,. S., Czikk, M. J., asilva, O., & Natale, R. (2005). The impact of labor at term on measures of neonatal outcome. merican Journal of Obstetrics an Gynecology, 192(1), Reason: Poorly esigne. Investigators state they exclue eaths attributable to labor, but they give no information on how they mae that istinction. Stuy fails to istinguish scar ehiscence from symptomatic scar rupture. Roberts, R. G., ell, H. S., Wall, E. M., Moy, J. G., Hess, G. H., & ower, H. P. (1997). Trial of labor or repeate cesarean section. The woman s choice. rchives of Family Meicine, 6(2), Reason: Other inclue SRs exclue stuies that faile to istinguish between scar ehiscence an rupture. This one faile to o so. Rosen, M. G., Dickinson, J.C., & Westhoff, C. L. (1991). Vaginal birth after cesarean: meta-analysis of morbiity an mortality. Obstetrics & Gynecology, 77(3), Reason: Other inclue SRs exclue stuies that faile to istinguish between scar ehiscence an rupture. This one faile to o so. Sims, E. J., Newman, R.., & Hulsey, T. C. (2001). Vaginal birth after cesarean: To inuce or not to inuce. merican Journal of Obstetrics an Gynecology, 184(6), Reason: Stuy exclue from Guise (2003) SR, an inclue stuy here. Stone, C., Halliay, J., Lumley, J., & rennecke, S. (2000). Vaginal births after Caesarean (VC): population stuy. Paeiatric an Perinatal Epiemiology, 14(4), Reason: Questionable generalizability an relevance. Stuy evaluates scar ruptures an perinatal eaths in ustralian women giving birth in 1995 whose birth immeiately prior to the inex birth was a cesarean. The VC rate (56%) was substantially below what can be achieve in women planning vaginal birth, making its generalizabilty questionable. The authors attribute this to excluing women with prior cesarean but a vaginal birth in the penultimate birth. Excluing these women also makes the relevance of the stuy questionable. The authors epen on ICD coes to etermine uterine rupture, but acknowlege that accuracy is poor. They cite a scar rupture rate in women having VC labor as 0.2% an no scar ruptures in women having repeat cesarean section. However, two occurre in multiparous women whose penultimate birth was vaginal, but who might have ha a cesarean prior to that, an two women whose previous birth route was not ientifie. This means the actual scar rupture rate in the VC group may have been higher than reporte. They exclue a case of scar rupture before labor in a multiparous woman whose penultimate birth an birth in 1995 were both cesareans. This is puzzling, as she woul seem to fit their criteria for inclusion. She woul then be a case of scar rupture in the planne cesarean group. ll in all, this stuy oes not seem to have any useful ata for supporting or refuting any of the VC rationales or establishing a reasonable VC rate. Taylor, D. R., Doughty,. S., Kaufman, H., Yang, L., & Iannucci, T.. (2002). Uterine rupture with the use of PGE2 vaginal inserts for labor inuction in women with previous cesarean sections. The Journal of Reprouctive Meicine, 47(7), Reason: Stuy not applicable. The high uterine rupture rate (1.8%) implies iatrogenic factors involve. Tucker, J. M., Hauth, J. C., Hogkins, P., Owen, J., & Winkler, C. L. (1993). Trial of labor after a one- or two-layer closure of a low transverse uterine incision. merican Journal of Obstetrics an Gynecology, 168(2), Step 6: Scientific Evience Goer, Leslie, & Romano 63S

67 Reason: Investigators compare scar rupture rates in VC labor in 149 women with singlelayer uterine suturing in prior elivery versus 143 women with ouble-layer suturing. If the absolute increase in scar rupture rate is a few percent, which it appears to be, base on larger stuies, this is still an important ifference, but this stuy is unerpowere to etect it. Uygur, D., Gun, O., Kelekci, S., Ozturk,., Ugur, M., & Mungan, T. (2005). Multiple repeat caesarean section: Is it safe? European Journal of Obstetrics, Gynecology, an Reprouctive iology, 119(2), Reason: Stuy lacks statistical strength. Investigators compare outcomes in 301 women with 2 or more prior cesareans with a control group of 301 women with 1 prior cesarean section. Only 44 women ha 3 or 4 prior cesareans. Stuy is unerpowere to etect uncommon but clinically important ifferences between groups in morbiity an certainly cannot etect ifferences in mortality. Moreover, investigators exclue women with placenta previa, which is strongly associate with the number of prior cesareans. Zelop, C. M, Shipp, T. D., Repke, J. T., Cohen,., Caughey,.., & Lieberman, E. (1999). Uterine rupture uring inuce or augmente labor in gravi women with one prior cesarean elivery. merican Journal of Obstetrics an Gynecology, 181(4), Reason: Stuy exclue from Guise (2003) SR, an inclue stuy here. Zweifler, J., Garza,., Hughes, S., Stanich, M.., Hierholzer,., & Lau, M. (2006). Vaginal birth after cesarean in California: before an after a change in guielines. nnals of Family Meicine, 4(3), Reason: Poorly esigne. This before-an-after stuy looks at the effect on maternal an neonatal mortality in California before an after stricter guielines for VC were implemente. Many factors coul affect results besies the ecrease in VCs. HENCI GOER is an awar-winning meical writer, author of The Thinking Woman s Guie to a etter irth an Obstetric Myths an Research Realities, an an internationally known speaker. n inepenent scholar, Goer is an acknowlege expert on evience-base maternity care. She is currently a resient expert for the Lamaze Institute for Normal irth an moerates the online Normal irth Forum ( MYRI SGDY LESLIE is a faculty member in the School of Nursing at Georgetown University in Washington, DC. She is also a member of the CIMS Leaership Team. MY ROMNO complete her nurse-miwifery training at Yale University School of Nursing an has practice in a birth center an in the home setting. She is currently a resient expert an the Web site eitor of the Lamaze Institute for Normal irth ( lamaze.org). 64S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

68 THE COLITION FOR IMPROVING MTERNITY SERVICES: EVIDENCE SIS FOR THE TEN STEPS OF MOTHER-FRIENDLY CRE Step 7: Eucates Staff in Nonrug Methos of Pain Relief an Does Not Promote Use of nalgesic, nesthetic Drugs The Coalition for Improving Maternity Services: Mayri Sagay Leslie, MSN, CNM my Romano, MSN, CNM Deborah Woolley, PhD, CNM, LCCE STRCT Step 7 of the Ten Steps of Mother-Frienly Care insures that staff are knowlegeable about nonrug methos of pain relief an that analgesic or anesthetic rugs are not promote unless require to correct a complication. The rationales for compliance an systematic reviews are presente on massage, hypnosis, hyrotherapy, an the use of opiois, regional analgesia, an anesthesia. Journal of Perinatal Eucation, 16(1 Supplement), 65S 73S, oi: / X Keywors: hypnosis an labor, hypnotherapy an labor, massage an labor, complementary therapies an labor, hyrotherapy an labor, waterbirth, water an birth, nonpharmacological pain management, analgesia an labor, nurses an pain labor, back pain an therapy an labor, movement an labor, posture an labor, maternal satisfaction, complementary therapy, opiois, epiural analgesia Step 7: Eucates staff in nonrug methos of pain relief an oes not promote the use of analgesic or anesthetic rugs not specifically require to correct a complication. Step 7: Eucates staff in nonrug methos of pain relief: massage, hypnosis, hyrotherapy. Nonrug Pain Relief Evience Grae For a escription an iscussion of the methos use to etermine the evience basis of the Ten Steps of Mother-Frienly Care, see this issue s Methos article by Henci Goer on pages 5S 9S. In contrast to meication, there is minimal to no risk of averse sie effects from nonrug methos of pain relief. Massage, hypnosis, an hyrotherapy have been shown to provie significant benefits. a In aition, the implementation of comfort measures, cognitive strategies, an other self-efficacy techniques can contribute to a woman s sense of mastery over the birth experience an, therefore, her satisfaction with herself an that experience (Lowe, 2002). Nonrug pain relief methos can be use alone or in conjunction with meicinal moes of pain relief an, as such, shoul be available to all laboring women in all settings. NEH (Continue ) Step 7: Pain Relief Leslie, Romano, & Woolley 65S

69 Members of the CIMS Expert Work Group were: For more information on the Coalition for Improving Maternity Services (CIMS) an copies of the Mother- Frienly Chilbirth Initiative an accompanying Ten Steps of Mother- Frienly Care, log on to the organization s Web site ( or call CIMS toll-free at (Continue) Nonrug Pain Relief Evience Grae When compare with similar populations receiving comparable clinical care, massage an encouraging touch ha the following benefits: reuce maternal pain (Huntley, 2004; Simkin, 2002). reuce maternal stress an anxiety (Huntley, 2004; Simkin, 2002). women state that the touch or massage helpe them cope with labor, ease their pain, an feel comforte, reassure, accepte, an encourage (Huntley, 2004; Simkin, 2001). When compare with similar populations receiving comparable clinical care, hypnosis uring labor ha the following benefits: reuce nee for analgesia (Cyna, 2004; Huntley, 2004; Smith, 2003). (2 meta-analyses) (The Smith metaanalysis foun no ifference in pain relief, although 2 of the 3 iniviual stuies i.) pain less severe than those not using hypnosis (Cyna, 2004; Huntley, 2004). greater maternal satisfaction with pain relief (Smith, 2003). Henci Goer,, Project Director (meta-analysis) Mayri Sagay Leslie, MSN, CNM shorter uration of labor (Cyna, 2004). Juith Lothian, PhD, RN, (meta-analysis) LCCE, FCCE my Romano, MSN, CNM reuce nee for augmentation of labor with oxytocin (Cyna, 2004; Smith, 2003). Karen Salt, CCE, M (meta-analysis) Katherine Shealy, MPH, ICLC, RLC Sharon Storton, M, increase incience of spontaneous births (Cyna, 2004; Smith 2003). CCHT, LMFT Deborah Woolley, PhD, CNM, LCCE Use of hypnosis ha no reporte averse effects in any stuy. NEH When compare with similar populations, women who use hyrotherapy (warm-water immersion in a tub) ha the following results: reuce maternal bloo pressure (Cluett, 2004, Cochrane). N** reporte less anxiety uring early labor (enfiel, 2001). C N* reporte less pain uring the first stage of labor (enfiel, 2001; Cluett, 2004, Cochrane; Simkin, 2002). (Continue ) 66S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

70 (Continue) Nonrug Pain Relief reuce nee for analgesia an/or anesthesia (Cluett, 2004, MJ; Cluett, 2004, Cochrane). Evience Grae reuce nee for augmentation in women with slow labors (Cluett, 2004, MJ). N* reporte feeling they cope better with pushing efforts (Cluett, 2004, Cochrane). ** N** fewer fetal malpresentations such as occiput posterior an eep occiput transverse positions (Simkin, 2002). reporte that hyrotherapy gave them more satisfaction with freeom of movement an with experience of privacy (Cluett, 2004, MJ). reporte that hyrotherapy gave them more control over the labor process, which was highly value (Hall, 1998). The use of hyrotherapy ha no averse effects with respect to: uration of labor, metho of elivery, infection in mother or baby, or umbilical cor ph, incluing when rupture of membranes occurre or amission to the neonatal intensive care unit (Simkin, 2002; enfiel, 2001; Cluett, 2004, MJ; Cluett, 2004, Cochrane). ¼ goo, ¼ fair, C ¼ weak, N ¼ not applicable, NEH ¼ no evience of harm Quality ¼ aggregate of quality ratings for iniviual stuies Quantity ¼ magnitue of effect, numbers of stuies, an sample size or power Consistency ¼ the extent to which similar finings are reporte using similar an ifferent stuy esigns *only one stuy **one stuy in SR a The benefits of continuous labor support from a traine or experience woman can be foun in Step 1 on p. 12S. The benefits of freeom of movement an nonsupine positioning for pushing an birth can be foun in Step 4 on pp. 25S 27S. Nonrug methos such as acupuncture an intraermal water injections have not been inclue in this review because they are more invasive an require specialize skills. irth in water, as oppose to hyrotherapy, is also not aresse because this is a clinical practice, not a pain-relief metho. N* N* NEH INCLUDED STUDIES enfiel, R. D., Herman, J., Katz, V. L., Wilson, S. P., & Davis, J. M. (2001). Hyrotherapy in labor. Research in Nursing & Health, 24(1), Cluett, E. R., Nikoem, V. C., McCanlish, R. E., & urns, E. E. (2004). Immersion in water in pregnancy, labour an birth. Cochrane Database of Systematic Reviews (2), CD Cluett, E. R., Pickering, R. M., Getliffe, K., & St. George Sauners, N. J. (2004). Ranomise controlle trial of labouring in water compare with stanar of augmentation for management of ystocia in first stage of labour. ritish Meical Journal, 328(7435), 314. Cyna,. M., Mculiffe, G. L., & nrew, M. I. (2004). Hypnosis for pain relief in labour an chilbirth: systematic review. ritish Journal of naesthesia, 93(4), Hall, S. M., & Holloway, I. M. (1998). Staying in control: Women s experiences of labour in water. Miwifery, 14(1), Huntley,. L., Coon, J. T., & Ernst, E. (2004). Complementary an alternative meicine for labor pain: systematic review. merican Journal of Obstetrics an Gynecology, 191(1), Lowe, N. K. (2002). The nature of labor pain. merican Journal of Obstetrics an Gynecology, 186(5 Suppl. Nature), S Simkin, P. P., & O Hara, M. (2002). Nonpharmacologic relief of pain uring labor: Systematic reviews of five methos. merican Journal of Obstetrics an Gynecology, 186(5 Suppl. Nature), S Smith, C.., Collins, C. T., Cyna,. M., & Crowther, C.. (2003). Complementary an alternative therapies for pain management in labour. Cochrane Database of Systematic Reviews, (2), CD EXCLUDED STUDIES nersen,., Gyghagen, M., & Nielsen, T. (1996). Warm bath uring labour. Effects on labour uration an Step 7: Pain Relief Leslie, Romano, & Woolley 67S

71 maternal an fetal infectious morbiity. Journal of Obstetrics an Gynaecology, 16, Reason: Data inclue in Simkin (2002). Cammu, H., Clasen, K., Van Wettere, L., & Dere, M. P. (1994). To bathe or not to bathe uring the first stage of labor. cta Obstetricia et Gynecologica Scaninavica, 73(6), Reason: Data inclue in Simkin (2002); Cluett (2004), MJ. Chang, M. Y., Wang, S. Y., & Chen, C. H. (2002). Effects of massage on pain an anxiety uring labour: ranomize controlle trial in Taiwan. Journal of vance Nursing, 38(1), Reason: Data inclue in Huntley (2004). Eckert, K., Turnbull, D., & MacLennan,. (2001). Immersion in water in the first stage of labor: ranomize controlle trial. irth, 28(2), Reason: Data inclue in Simkin (2002); Cluett (2004), MJ. Eriksson, M., Mattsson, L.., & Lafors, L. (1997). Early or late bath uring the first stage of labour: ranomise stuy of 200 women. Miwifery, 13(3), Reason: Data inclue in Simkin (2002); Cluett (2004), MJ. Fiel, T., Hernanez-Reif, M., Taylor, S., Quintino, O., & urman, I. (1997). Labor pain is reuce by massage therapy. Journal of Psychosomatic Obstetrics an Gynaecology, 18(4), Reason: Data inclue in Simkin (2002). Harmon, T. M., Hynan, M. T., & Tyre, T. E. (1990). Improve obstetric outcomes using hypnotic analgesia an skill mastery combine with chilbirth eucation. Journal of Consulting an Clinical Psychology, 58(5), Reason: Data inclue in Huntley (2004); Cyna (2004). Labrecque, M., Nouwen,., ergeron, M., & Rancourt, J. F. (1999). ranomize controlle trial of nonpharmacologic approaches for relief of low back pain uring labor. The Journal of Family Practice, 48(4), Reason: Data inclue in Simkin (2002). Lenstrup, C., Schantz,., erget,., Feer, E., Roseno, H., & Hertel, J. (1987). Warm tub bath uring elivery. cta Obstetricia et Gynecologica Scaninavica, 66(8), Reason: Data inclue in Simkin (2002). Martin,.., Schauble, P. G., Rai, S. H., & Curry, R. W, Jr. (2001). The effects of hypnosis on the labor processes an birth outcomes of pregnant aolescents. The Journal of Family Practice, 50(5), Reason: Data inclue in Smith (2003). Ohlsson, G., uchhave, P., Leanersson, U., Norstrom, L., Ryhstrom, H., & Sjolin, I. (2001). Warm tub bathing uring labor: Maternal an neonatal effects. cta Obstetricia et Gynecologica Scaninavica, 80(4), Reason: Data inclue in Simkin (2002); Cluett (2004), MJ. Rush, J., urlock, S., Lambert, K., Loosley-Millman, M., Hutchison,., & Enkin, M. (1996). The effects of whirlpool baths in labor: ranomize, controlle trial. irth, 23(3), Reason: Data inclue in Simkin (2002); Cluett (2004), MJ. Schorn, M. N., Mcllister, J. L., & lanco, J. D. (1993). Water immersion an the effect on labor. Journal of Nurse-Miwifery, 38(6), Reason: Data inclue in Simkin (2002); Cluett (2004), MJ. Step 7: Does not promote the use of analgesic or anesthetic rugs not specifically require to correct a complication Opiois The opiois commonly use in labor are one of several synthetic erivatives of morphine or morphine itself injecte either intramuscularly or intravenously. Derivatives inclue Demerol/Pethiine/ meperiine; Staol/butorphanol; Nubain/nalbuphine; an Dilaue/hyromorphone. Opiois Opiois may cause unpleasant sie effects such as rowsiness, nausea, an vomiting (ricker, 2002; Tsui, 2004). Evience Grae Newborns of women who use opiois uring labor (ricker, 2002): can experience respiratory epression in the first hours following birth. (SR with multiple stuies) can be less alert in the first hours following birth. (SR with multiple stuies) (Continue ) 68S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

72 (Continue) Opiois Evience Grae can experience a elay in the onset of successful feeing. (SR with multiple stuies) may be more likely to become aicte to opiois or amphetamines in later life. ¼ goo, ¼ fair, C ¼ weak, SR ¼ systematic review Quality ¼ aggregate of quality ratings for iniviual stuies Quantity ¼ magnitue of effect, numbers of stuies, an sample size or power Consistency ¼ the extent to which similar finings are reporte using similar an ifferent stuy esigns C (SR with multiple stuies) INCLUDED STUDIES ricker, L., & Lavener, T. (2002). Parenteral opiois for labor pain relief: systematic review. merican Journal of Obstetrics an Gynecology, 186(5 Suppl. Nature), S Tsui, M. H. Y., Kee, W. D. N., Ng, F. F., & Lau, T. K. (2004). ouble-bline ranomize placebo-controlle stuy of intramuscular pethiine for pain relief in the first stage of labour. JOG, 111, EXCLUDED STUDIES None Step 7: Does not promote the use of analgesic or anesthetic rugs not specifically require to correct a complication: Regional anesthesia/analgesia Regional nesthesia/nalgesia Regional anesthesia/analgesia for labor inclues the epiural an the combine spinal/epiural. The research that examines regional anesthesia/analgesia for labor is confoune by the following factors: Few stuies compare groups using various pain meications with groups that use none. lmost all women in publishe comparative stuies have been expose to rugs, proceures, an restrictions that coul also aversely affect the mother, baby, or labor pattern. Large percentages of women in many of the ranomize controlle trials who are assigne to the no epiural group ultimately have epiurals. This reuces the likelihoo of etecting ifferences between groups. ackgroun cesarean rates in several ranomize controlle trials are much lower than foun in reports of conventional obstetric management. This means that factors influencing outcomes, such as timing of epiural initiation an policies an philosophies regaring management of women with epiurals, are not taken into account. Consequently, trial results cannot be generalize to conventionally manage populations. ackgroun cesarean rates may be so high that the use or nonuse of epiurals can have little influence. Regional nesthesia/nalgesia Compare with epiural anesthesia without the aition of intrathecal opiois, babies in utero of women receiving a combine spinal/epiural (with intrathecal opiois) may be more likely to experience braycaria (Lieberman, 2002; Marirosoff, 2002). Evience Grae (Continue ) Step 7: Pain Relief Leslie, Romano, & Woolley 69S

73 (Continue) Regional nesthesia/nalgesia Evience Grae Compare with epiural anesthesia without the aition of opiois, women receiving a combine spinal/epiural (with opiois): can experience severe itching (Mayberry, 2002). may be more seate (Mayberry, 2002). Compare with women ranomly assigne to using no pain meication or exclusively opioi pain meication uring labor, women ranomly assigne to having epiurals: may experience a longer first-stage labor (lexaner, 2002; nim-somuah, 2006; Lieberman, 2002; Sharma, 2004). can experience a longer secon-stage labor (lexaner, 2002; nim-somuah, 2006; Feinstein, 2002; Lieberman, 2002; Liu, 2004; Sharma, 2004). have increase likelihoo of malposition of the fetal hea (nim-somuah, 2006; Lieberman, 2002). have increase likelihoo of oxytocin use (lexaner, 2002; nim-somuah, 2006; Liu, 2004; Sharma, 2004). have increase likelihoo of hypotension (nim-somuah, 2006). have increase likelihoo of instrumental vaginal elivery (lexaner, 2002; nim-somuah, 2006; Lieberman, 2002; Liu, 2004; Sharma, 2004). have increase likelihoo of thir- an fourth-egree tears associate with the increase incience of instrumental vaginal eliveries (Lieberman, 2002). may have increase likelihoo of cesarean section for fetal istress (nim-somuah, 2006; Liu, 2004). may have increase likelihoo of having a cesarean for ystocia (nim-somuah, 2006; Feinstein, 2002; Liu, 2004). have increase likelihoo of fever uring labor (nim-somuah, 2006; Lieberman, 2002). a The newborns of women who ha a fever in labor may be more likely to experience seizures in the neonatal perio (Lieberman, 2002). Compare with babies in utero of women not using pain meication, the fetuses of women having epiurals may have increase incience of transient heart-rate abnormalities (Lieberman, 2002). C C C (Continue ) 70S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

74 (Continue) Regional nesthesia/nalgesia Compare with newborns of women who i not receive intrathecal narcotics, the newborns of women who i receive intrathecal narcotics may experience more ifficulty breastfeeing uring the first hours/ays after birth, in irect proportion to the amount of intrathecal narcotic the mother receive (eilin, 2005; Joran, 2005; Lieberman, 2002; Razyminski, 2003, 2005). Evience Grae Compare with the newborns of women not using pain meication, the newborns of women having epiurals have increase likelihoo of jaunice (Lieberman, 2002). Epiural placement before 4 cm ilation may increase (Lieberman, 2002): the likelihoo of fetal malposition. C C the likelihoo of instrumental vaginal elivery. the likelihoo of cesarean section. Women whose epiurals are iscontinue late in labor (rather than after birth) o not emonstrate a ecrease incience of the averse elivery outcomes associate with epiurals (Lieberman, 2002; Torvalsen, 2004). Women having epiurals may be more likely to experience hemorrhage immeiately after birth. (Lieberman, 2002). Women having epiurals may be more likely to experience ifficulty urinating in the first few hours after birth (nim-somuah, 2006; Lieberman, 2002). ¼ goo, ¼ fair, C ¼ weak Quality ¼ aggregate of quality ratings for iniviual stuies Quantity ¼ magnitue of effect, numbers of stuies, an sample size or power Consistency ¼ the extent to which similar finings are reporte using similar an ifferent stuy esigns *only one stuy a ecause newborns are especially vulnerable to infection, babies born to mothers who run fevers in labor are likely to be separate from their mothers for observation in the nursery, unergo septic workups, an possibly have prophylactic IV antibiotic therapy until cultures rule out infection. This subjects the baby to painful, unpleasant proceures; interferes with boning an establishing breastfeeing; an can greatly increase parental anxiety. b Wong (2005), an exclue stuy, has been cite as evience that early epiural placement, as compare with later placement, oes not affect cesarean rates. It is not inclue as evience for this rationale because this trial i not actually compare early to late epiurals. Women in the early epiural arm were given spinals/epiurals. Most i not receive the epiural component until 4 cm ilation or later, the same timing as the late epiural group. Spinal opioi, in contrast to epiural anesthetic, has not been shown to affect labor progress. Klein (2006) observes that neither previous nor current Cochrane reviewers of epiural versus nonepiural analgesia evaluate the effect of late versus early epiural initiation. If they ha, Klein notes they woul have foun that early epiural placement more than ouble the likelihoo of cesarean elivery OR 2.59 (95% CI ). C C b N* REFERENCE Klein, M. C. (2006). Epiural analgesia: Does it or oesn t it? irth, 33(1), INCLUDED STUDIES lexaner, J., Sharma, S., McIntire, D., & Leveno, K. (2002). Epiural analgesia lengthens the Frieman active phase of labor. Obstetrics an Gynecology, 100 (2), nim-somuah, M., Smyth, R., & Howell, C. (2006). Epiural versus non-epiural or no analgesia in labour. Cochrane Database of Systematic Reviews (1). eilin, Y., oian, C.., Weiser, J., Hossain, S., rnol, I., Feierman, D. E., et al. (2005). Effect of labor epiural analgesia with an without fentanyl on infant breastfeeing. nesthesiology, 103(6), Feinstein, U., Sheiner, E., Levy,., Hallak, M., & Mazor, M. (2002). Risk factors for arrest of escent uring the Step 7: Pain Relief Leslie, Romano, & Woolley 71S

75 secon stage of labor. International Journal of Gynaecology an Obstetrics, 77(1), Joran, S., Emery, S., rashaw, C., Watkins,., & Friswell, W. (2005). The impact of intrapartum analgesia on infant feeing. JOG, 112, Lieberman, E., & O Donoghue, C. (2002). Unintene effects of epiural analgesia uring labor: systematic review. merican Journal of Obstetrics an Gynecology, 186(5), S31 S68. Liu, E., & Sia,. (2004). Rates of caesarean section an instrumental vaginal elivery in nulliparous women after low concentration epiural infusions or opioi analgesia: Systematic review. ritish Meical Journal, 328, Marirosoff, C., Dumont, L., oulvain, C., & Tramer, M. (2002). Fetal braycaria ue to intrathecal opiois for labour analgesia: systematic review. JOG, 109, Mayberry, L. J., Clemmens, D., & De,. (2002). Epiural analgesia sie effects, co-interventions, an care of women uring chilbirth: systematic review. merican Journal of Obstetrics an Gynecology, 186(5 Suppl. Nature), S Razyminski, S. (2003). The effect of ultra low ose epiural analgesia on newborn breastfeeing behaviors. Journal of Obstetric, Gynecologic, an Neonatal Nursing, 23(3), Razyminski, S. (2005). Neurobehavioral functioning an breastfeeing behavior in the newborn. Journal of Obstetric, Gynecologic, an Neonatal Nursing, 34(3), Sharma, S., McIntire, D., Wiley, J., & Leveno, K. (2004). Labor analgesia an cesarean elivery: n iniviual patient meta-analysis of nulliparous women. nesthesiology, 100, Torvalsen, S., Roberts, C., ell, J., & Raynes-Greenow, C. (2004). Discontinuation of epiural analgesia late in labour for reucing the averse elivery outcomes associate with epiural analgesia. The Cochrane Database of Systematic Reviews (4). EXCLUDED STUDIES aumgarer, D.J., Muehl, P., Fischer, J., & Pribbenow,. (2003). Effect of labor epiural anesthesia on breast-feeing of healthy full-term newborns elivere vaginally. The Journal of the merican oar of Family Practice, 16, Reason: Poorly esigne. Di not control for or escribe meications use in the epiural. Stuy too small. Results not statistically significant after stratifying by parity, which is a significant confouner. Chang, Z. M., & Heaman, J. I. (2005). Epiural analgesia uring labor an elivery: Effects on the initiation an continuation of effective breastfeeing. Journal of Human Lactation, 21(3), Reason: Poorly esigne. High potential for self-selection bias. lthough there is a power calculation, authors amit it was not vali for the instruments they ultimately use. Stuy i not control for or escribe type or ose of epiural infusions. Choi, P., Galinski, S., Takeuchi, L., Tamayo, C., & Jaa,. (2003). PDPH is a common complication blockae in parturients: meta-analysis of obstetrical stuies. Canaian Journal of naesthesia, 50(5), Reason: Planne meta-analysis, but stuies extracte too heterogeneous, so limite analysis to narrative on onset an uration, with small meta-analysis of poole ata. Dickinson, J., Paech, M., McDonal, S., & Evans, S. (2002). The impact of intrapartum analgesia on labour an elivery outcomes in nulliparous women. The ustralian & New Zealan Journal of Obstetrics & Gynaecology, 42(1), Reason: Data inclue in most recent Cochrane systematic reviews. Eriksson, S., Olausson, P., & Olofsson, C. (2005). Use of epiural analgesia an its relation to caesarean an instrumental eliveries population-base stuy of 94,217 primiparae. European Journal of Obstetrics, Gynecology, an Reprouctive iology, 128, 1 6. Reason: Poorly esigne. The stuy estimate the number of subjects who use epiurals an i not connect each subject with her own outcomes. Henerson, J., Dickinson, J., Evans, S., McDonal, S., & Paech, M. (2003). Impact of intrapartum epiural analgesia on breast-feeing uration. The ustralian & New Zealan Journal of Obstetrics & Gynaecology, 43, Reason: Intene to be a ranomize controlle trial but was converte to observational stuy because of high crossover rate. Conclusions a nothing to the boy of knowlege. This issue is aresse in nim-somuah (2006) Cochrane review. Howell, C. (1999). Epiural versus non-epiural analgesia for pain relief in labour. The Cochrane Database of Systematic Reviews (3). Reason: Stuy supersee by nim-somuah (2006). Howell, C., Dean, T., Lucking, L., Dziezic, K., Jones, P., & Johanson, R. (2002). Ranomise stuy of longterm outcome after labour epiural versus non-epiural analgesia uring labour. ritish Meical Journal, 325, Reason: Data inclue in nim-somah (2006). Leighton,. L., & Halpern, S. H. (2002). The effects of epiural analgesia on labor, maternal, an neonatal outcomes: systematic review. merican Journal of Obstetrics an Gynecology, 186 (5 Suppl. Nature), S Reason: Poorly esigne. Data are contaminate by many variables. Lieberman & O Donoghue (2002) provie a much more inclusive an reasone review whose conclusions are much clearer an more likely to be vali. Negishi, C., Lenhart, R., Ozaki, M., Ettinger, K., astanmeher, H., jorksten,., et al. (2001). Opiois inhibit febrile responses in humans, whereas epiural analgesia oes not: n explanation for hyperthermia uring epiural analgesia. nesthesiology, 94, Reason: Not applicable. Number an gener of subjects (one on 8 male subjects) prevent results from being applicable to pregnant women. Nystet,., Evarsson, D., & Willman,. (2004). Epiural analgesia for pain relief in labour an chilbirth review with a systematic approach. Journal of Clinical Nursing, 13, Reason: Poorly esigne. 72S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

76 This review use articles relatively easy to fin in Meline an CINHL (but no other atabase), because the authors wante to see what kin of ata busy clinicians might be likely to encounter. There are better-quality ata in nim-somuah (2006). Reynols, F., Sharma, S., & See, P. (2002). nalgesia in labour an fetal aci-base balance: a meta-analysis comparing epiural with systemic opioi analgesia. JOG, 109, Reason: Have better-quality, more recent research. Volmanen, P., Valanne, J., & lahuhta, S. (2004). reastfeeing problems after epiural analgesia for labour: a retrospective cohort stuy of pain, obstetrical proceures an breast-feeing practices. International Journal of Obstetric nesthesia, 13, Reason: Not relevant. Ol ata with small response rate. Wong, C.., Scavone,. M., Peaceman,. M., McCarthy, R. J., Sullivan, J. T., Diaz, N. T., et al. (2005). The risk of cesareaneliverywithneuraxialanalgesiagivenearlyversus late in labor. New Englan Journal of Meicine, 352(7), Reason: Poorly esigne. Ranomization unsuccessful; two groups iffere little in actual timingofepiuralinlabor. MYRI SGDY LESLIE is a faculty member in the School of Nursing at Georgetown University in Washington, DC. She is also a member of the CIMS Leaership Team. MY ROMNO complete her nurse-miwifery training at Yale University School of Nursing an has practice in a birth center an in the home setting. She is currently a resient expert an the Web site eitor of the Lamaze Institute for Normal irth ( lamaze.org). DEORH WOOLLEY is a former presient of Lamaze International. She is currently a clinical specialist in the irth Center at Palomar Meical Center in Esconio, California. Step 7: Pain Relief Leslie, Romano, & Woolley 73S

77 THE COLITION FOR IMPROVING MTERNITY SERVICES: EVIDENCE SIS FOR THE TEN STEPS OF MOTHER-FRIENDLY CRE Step 8: Encourages ll Mothers, Families to Touch, Hol, reastfee, Care for Their abies The Coalition for Improving Maternity Services: Sharon Storton, M, CCHT, LMFT STRCT Step 8 of the Ten Steps to Mother-Frienly Care encourages all mothers an families, incluing those with sick or premature newborns or infants with congenital problems, to touch, hol, breastfee, an care for their babies to the extent compatible with their conitions. The rationales for compliance with the step an systematic review are presente. Journal of Perinatal Eucation, 16(1 Supplement), 74S 76S, oi: / X Keywors: parent care of ill or premature neonates or infants, neonatal intensive care, NICU, an parents For a escription an iscussion of the methos use to etermine the evience basis of the Ten Steps of Mother-Frienly Care, see this issue s Methos article by Henci Goer on pages 5S 9S. Step 8: Encourages all mothers an families, incluing those with sick or premature newborns or infants with congenital problems, to touch, hol, breastfee, an care for their babies to the extent compatible with their conitions. Keeping mothers an babies together, incluing infants with meical problems, enhances attachment, increases breastfeeing initiation an uration, an ecreases infant stress. There is no evience of harm in encouraging mothers an families to touch, hol, breastfee, an care for their babies to the extent compatible with their conition. Touch, Hol, reastfee No evience of harm was foun for encouraging mothers an families to touch, hol, breastfee, an care for their babies to the extent compatible with their conitions. No evience of harm was foun for encouraging mothers an families of sick or premature infants or infants with congenital problems to touch, hol, breastfee, an care for their infants to the extent compatible with their conitions. Touching, holing, an caring for healthy infants enhance attachment between mothers an babies (nerson, 2003; DiMatteo, 1996; Klaus, 1998; Rowe-Murray, 2001; Wenlan-Carro, 1999). Evience Grae NEH NEH (Continue ) 74S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

78 (Continue) Touch, Hol, reastfee Touching, holing, an caring for sick or premature infants or infants with congenital problems enhances attachment between mothers an babies (Charpak, 2001; DiMatteo, 1996; Felman, 1999; Klaus, 1998; Rowe-Murray, 2001; Schroeer, 2006; Tessier, 1998; Wenlan-Carro, 1999). Eliminating or minimizing separation for proceures whenever possible reuces istress in healthy infants an mothers (nerson, 2003; Gray, 2000; Klaus, 1998). Eliminating or minimizing separation for proceures whenever possible reuces istress in sick or premature infants, infants with congenital problems, an mothers (Felman, 1999; Klaus, 1998; Mörelius, 2005). Minimizing separation uring the hospital stay increases breastfeeing initiation an uration in mothers with healthy infants (nerson, 2003; Klaus, 1998). Unimpee early skin-to-skin contact increases breastfeeing initiation an uration in mothers with healthy infants (nerson, 2003; Klaus, 1998). reastfeeing is universally accepte as the biologically normal human infant-feeing metho. Lack of breastfeeing accounts for 13% of all eaths among chilren uner 5 years of life, worlwie (Jones, 2003). Infants in the Unite States who are not breastfe are 25% more likely to ie between 28 ays an 1 year of life than breastfe infants (Chen, 2004). mother s relative risk of acquiring breast cancer ecreases 4.3% for every 12 months of breastfeeing, above an beyon the 7% risk reuction for each birth (Collaborative Group on Hormonal Factors in reast Cancer, 2002). Infants shoul be exclusively breastfe for the first 6 months of life, followe by appropriate introuction of complementary foos an continue breastfeeing (Kramer, 2004). reastfeeing mitigates the harmful effects of organochlorine compouns to which infants are expose prenatally. (Ribas-Fito, 2003). ¼ goo, ¼ fair, N ¼ not applicable, NEH ¼ no evience of harm Quality ¼ aggregate of quality ratings for iniviual stuies Quantity ¼ magnitue of effect, numbers of stuies, an sample size or power Consistency ¼ the extent to which similar finings are reporte using similar an ifferent stuy esigns *only 1 stuy **multiple stuies in SR INCLUDED STUDIES nerson, G., Moore, E., Hepworth, J., & ergman, N. (2003). Early skin-to-skin contact for mothers an their healthy newborn infants. The Cochrane Database of Systematic Reviews, (2). rt No: CD DOI: / CD Charpak, N., Ruiz-Pelaez, J., Figueroa e, C. Z., & Charpak, Y. (2001). ranomize, controlle trial of kangaroo mother care: Results of follow-up at 1 year of correcte age. Peiatrics, 108(5), Chen,., & Rogan, W. (2004). reastfeeing an the risk of postneonatal eath in the Unite States. Peiatrics, 113(5), e Evience Grae Collaborative Group on Hormonal Factors in reastcancer. (2002). reast cancer an breastfeeing: Collaborative reanalysis of iniviual ata from 47 epiemiological stuies in 30 countries incluing 50,302 women with breast cancer an 96,973 women without the isease. Lancet, 360, DiMatteo, M. R., Morton, S., Lepper, H., Damush, T. M., Carney, M. F., Pearson, M., et al. (1996). Cesarean chilbirth an psychosocial outcomes: meta-analysis. Health Psychology, 15(4), Felman, R., Weller,., Leckman, J., Kuint, J., & Eielman,. I. (1999). The nature of the mother s tie to her infant: Maternal boning uner conitions of N* ** ** N* For more information on the Coalition for Improving Maternity Services (CIMS) an copies of the Mother- Frienly Chilbirth Initiative an accompanying Ten Steps of Mother-Frienly Care, log on to the organization s Web site ( org) or call CIMS tollfree at Members of the CIMS Expert Work Group were: Henci Goer,, Project Director Mayri Sagay Leslie, MSN, CNM Juith Lothian, PhD, RN, LCCE, FCCE my Romano, MSN, CNM Karen Salt, CCE, M Katherine Shealy, MPH, ICLC, RLC Sharon Storton, M, CCHT, LMFT Deborah Woolley, PhD, CNM, LCCE Step 8: Touch, Hol, reastfee Storton 75S

79 proximity, separation an potential loss. Journal of Chil Psychology an Psychiatry, an llie Disciplines, 40(6), Gray,L.,Watt,L.,&lass,E.(2000).Skin-to-skincontactis analgesic in healthy newborns. Peiatrics, 105(1), Jones, G., Steketee, R., lack, R., hutta, Z., & Morris, S. (2003). ellagio Chil Survival Stuy Group. How many chil eaths can we prevent this year? Lancet, 362, Klaus, M. (1998). Mother an infant: Emotional ties. Peiatrics, 102, Kramer, M. S., & Kakuma, R. (2004). The optimal uration of exclusive breastfeeing: systematic review. vances in Experimental Meicine an iology, 554, Mörelius, E., Theoorsson, E., & Nelson, N. (2005). Salivary cortisol an moo an pain profiles uring skin-to-skin care for an unselecte group of mothers an infants in neonatal intensive care. Peiatrics, 116(5), Ribas-Fito,N.,Caro,E.,Sala,M.,EulaliaeMuga,M., Mazon,C.,&Veru,.,etal.(2003).reastfeeing, exposure to organochlorine compouns, an neuroevelopment in infants. Peiatrics, 111(5), e580 e585. Rowe-Murray, H., & Fisher, J. (2001). Operative intervention in elivery is associate with compromise early mother-infant interaction. ritish Journal of Obstetrics an Gynaecology, 108, Schroeer, M., & Priham, K. (2006). Development of competencies through guie participation for mothers of preterm infants. Journal of Obstetric, Gynecologic, an Neonatal Nursing, 35(3), Tessier,R.,Cristo,M.,Velez,S.,Giron,M.,Calume,eZ.F., Ruiz-Palaez, J. G., et al. (1998). Kangaroo mother care an the boning hypothesis. Peiatrics, 102(2), Wenlan-Carro, J., Piccinini, C., & Millar, W. S. (1999). The role of an early intervention on enhancing the quality of mother-infant interaction. Chil Development, 70(3), EXCLUDED STUDIES uranasin,. (1991). The effects of rooming in on the success of breastfeeing an the ecline in abanonment of chilren. sia-pacific Journal of Public Health, 5, Reason: Data inclue in Klaus (1998). Christensson, K., Cabrera, T., Christensson, E., Uvnas- Moberg, K., & Winberg, J. (1995). Separation istress call in the human neonate in the absence of maternal boy contact. cta Paeiatrica, 84, Reason: Inclue in nerson (2003). Gartner, L., Morton, J., Lawrence, R.., et al. (2005). reastfeeing an the use of human milk. Peiatrics, 115(2), Reason: Not relevant. Material is P recommenation, not a systematic review. Goling, J., Emmett, P. M., & Rogers, I. S. (1997). reastfeeing an infant mortality. Early Human Development, 49, S143 S155. Reason: Data inclue in Chen (2004). Lopez-larcon, M., Villalpano, S., & Fajaro,. (1997). reastfeeing lowers the frequency an uration of acute respiratory infection an iarrhea in infants uner six months of age. The Journal of Nutrition, 127, Reason: Data inclue in Chen (2004). McVea, K., Turner, P., & Peppler, D. (2000). The role of breastfeeing in suen infant eath synrome. Journal of Human Lactation, 16(1), Reason: Data inclue in Chen (2004). Michelsson, K., Christensson, K., Rothganger, H., & Winberg, J. (1996). Crying in separate an nonseparate newborns: Soun spectrographic analysis. cta Paeiatrica, 85, Reason: Upate ata in nerson (2003). Nyqvist, K. H., Sjoen, P. O., & Ewal, U. (1994). Mothers avice about facilitating breastfeeing in a neonatal intensive care unit. Journal of Human Lactation, 10, Reason: Not relevant. rticle is a survey, not a stuy. Pury, I. (2006). Embracing bioethics in neonatal intensive care, Part I: Evolving towar neonatal eviencebase ethics; Part II: Case histories in neonatal ethics. Neonatal Network, 25(1), 33 42, Reason: Not relevant. Righar, L., & lae, M. O. (1994). Effect of elivery routines on success of first breastfeeing. Lancet, 336, Reason: Data inclue in Klaus (1998). WHO Collaborative Stuy Team on the Role of reastfeeing in the Prevention of Infant Mortality. (2001). Effect of breastfeeing on infant an chil mortality ue to infectious iseases in less evelope countries: poole analysis. Lancet, 355, Reason: Not relevant. Recommenation, not a systematic review. Yngve,., & Sjostrom, M. (2001). reastfeeing in countries of the European Union an EFT: Current an propose recommenations, rationale, prevalence, uration an trens. Public Health Nutrition, 4, Reason: Data inclue in Chen (2004). SHRON STORTON is a psychotherapist who specializes in women s mental health an trauma recovery. She is also a member of the CIMS Leaership Team. 76S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

80 THE COLITION FOR IMPROVING MTERNITY SERVICES: EVIDENCE SIS FOR THE TEN STEPS OF MOTHER-FRIENDLY CRE Step 9: Discourages Nonreligious Circumcision of the Newborn The Coalition for Improving Maternity Services: Karen Salt, CCE, M my Romano, MSN, CNM STRCT Step 9 of the Ten Steps of Mother-Frienly Care iscourages nonreligious circumcision of the newborn. The rationale for compliance an systematic review are presente. Journal of Perinatal Eucation, 16(1 Supplement), 77S 78S, oi: / X Keywors: circumcision, pain an circumcision, urinary tract infection an circumcision Step 9: Discourages nonreligious circumcision of the newborn. lthough a number of stuies suggest that circumcision may confer some benefit in aulthoo (a reuce risk of rare penile cancer an ecrease risk of HIV infection in some populations), members of the Expert Work Group (EWG) of the Coalition for Improving Maternity Services (CIMS) chose to exclue from review stuies of aults. No evience confirms that circumcision nees to be performe in the newborn perio in orer to prevent conitions that present in aolescence or aulthoo. ult males can make their own informe ecisions relate to prophylactic circumcision. The EWG reviewe stuies of infants an young chilren an note the research on pain experience uring infant circumcision an the availability of lower-risk strategies to reuce the risk of urinary tract infection in infants. For a escription an iscussion of the methos use to etermine the evience basis of the Ten Steps of Mother-Frienly Care, see this issue s Methos article by Henci Goer on pages 5S 9S. Discourages Non-Religious Circumcision Circumcision of the male newborn is the most common proceure performe on chilren worlwie (Singh-Grewal, 2005). lthough practitioners avocating for routine circumcision of newborns cite stuies suggesting that circumcision may reuce the risk of certain iseases, they fail to aress: No-risk or lower-risk alternatives that may achieve the same benefits, such as breastfeeing to reuce urinary tract infections in infants. Pain experience by the newborn. lthough practitioners avocate a number of pain-management strategies, no intervention completely eliminates the pain response in newborns unergoing circumcision (ray-fryer, 2004). Newborns experience pain postcircumcision. Evience Grae NE (Continue ) For more information on the Coalition for Improving Maternity Services (CIMS) an copies of the Mother- Frienly Chilbirth Initiative an accompanying Ten Steps of Mother-Frienly Care, log on to the organization s Web site ( or call CIMS toll-free at Step 9: Circumcision Salt & Romano 77S

81 Members of the CIMS Expert Work Group were: (Continue) Discourages Non-Religious Circumcision Henci Goer,, Project Director Mayri Sagay Leslie, MSN, CNM Juith Lothian, PhD, RN, LCCE, FCCE my Romano, MSN, CNM Karen Salt, CCE, M Katherine Shealy, MPH, ICLC, RLC Sharon Storton, M, CCHT, LMFT Deborah Woolley, PhD, CNM, LCCE More uncircumcise infant males will experience urinary tract infections in the first 3 years of life, with protective effects of circumcision iminishing over time. This will be offset by a 2 10% complication rate associate with the proceure. ssuming a 2% complication rate, circumcising 1,000 urologically normal infant males will prevent 9 cases of urinary tract infection, but provoke complications in 20 babies (Singh-Grewal, 2005). ¼ goo, ¼ fair, NE ¼ no evience of benefit Quality ¼ aggregate of quality ratings for iniviual stuies Quantity ¼ magnitue of effect, numbers of stuies, an sample size or power Consistency ¼ the extent to which similar finings are reporte using similar an ifferent stuy esigns INCLUDED STUDIES ray-freyer,., Wiebe, N., & Laner, J.. (2004). Pain relief for neonatal circumcision. Cochrane Database of Systematic Reviews (3): CD Singh-Grewal, D., Macessi, J., & Craig, J. (2005). Circumcision for the prevention of urinary tract infection in boys: systematic review of ranomize trials an observational stuies. rchives of Disease in Chilhoo, 90, EXCLUDED STUDIES Newman,. G., & ustin, E. (2002). Making the cut? Dealing with the complications of incomplete circumcisions. Neonatal Intensive Care, 15(6), 39 41, 50. Reason: Poorly esigne. Sample size too small Rickwoo,. M. K., Kenny, S. E., & Donnell, S. C. (2000). Towars evience-base circumcision of English boys: Survey of trens in practice. MJ, 321, Evience Grae Reason: Not applicable. Stuy looks at practice trens. Schoen, E. J., Colby, C. J., & Ray, G. T. (2000). Newborn circumcision ecreases incience an costs of urinary tract infections uring the first year of life. Peiatrics, 105(4.1), Reason: Stuy supersee by Singh-Grewal, Macessi, an Craig (2005). KREN SLT is an author, chilbirth eucator, oula, an former cochair of the Coalition for Improving Maternity Services. She currently attens Purue University in West Lafayette, Iniana, as a full-time octoral stuent, specializing in nationalism, race, an gener stuies. MY ROMNO complete her nursemiwifery training at Yale University School of Nursing an has practice in a birth center an in the home setting. She is currently a resient expert an the Web site eitor of the Lamaze Institute for Normal irth ( 78S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

82 THE COLITION FOR IMPROVING MTERNITY SERVICES: EVIDENCE SIS FOR THE TEN STEPS OF MOTHER-FRIENDLY CRE Step 10: Strives to chieve the WHO/ UNICEF Ten Steps of the aby-frienly Hospital Initiative to Promote Successful reastfeeing The Coalition for Improving Maternity Services STRCT Step 10 of the Ten Steps of Mother-Frienly Care is the Ten Steps to aby-frienly. These steps promote, protect, an support breastfeeing. Rationales for compliance with the WHO/UNICEF Ten Steps of the aby-frienly Hospital Initiative an a systematic review of the evience relate to the impact of the Ten Steps to aby-frienly on breastfeeing are presente. Journal of Perinatal Eucation, 16(1 Supplement), 79S 80S, oi: / X Keywors: breastfeeing, aby-frienly Hospital Initiative, hospital practices an breastfeeing Step 10: Strives to achieve the WHO-UNICEF Ten Steps of the aby-frienly Hospital Initiative to promote successful breastfeeing: Have a written breastfeeing policy that is routinely communicate to all health-care staff. Train all health-care staff in skills necessary to implement this policy. Inform all pregnant women about the benefits an management of breastfeeing. Help mothers initiate breastfeeing within one half-hour of birth. Show mothers how to breastfee an how to maintain lactation even if they shoul be separate from their infants. Give newborn infants no foo or rink other than breast milk, unless meically inicate. Practice rooming in: llow mothers an infants to remain together 24 hours a ay. Encourage breastfeeing on eman. Give no artificial teat or pacifiers (also calle ummies or soothers ) to breastfeeing infants. Foster the establishment of breastfeeing support groups an refer mothers to them on ischarge from hospitals or clinics. For a escription an iscussion of the methos use to etermine the evience basis of the Ten Steps of Mother-Frienly Care, see this issue s Methos article by Henci Goer on pages 5S 9S. The Ten Steps to aby-frienly has influence change in hospital practices, which has ha a positive impact on breastfeeing uration an some inices of infant health. Step 10: Successful reastfeeing CIMS 79S

83 For more information on the Coalition for Improving Maternity Services (CIMS) an copies of the Mother-Frienly Chilbirth Initiative an accompanying Ten Steps of Mother-Frienly Care, log on to the organization s Web site ( org) or call CIMS tollfree at Members of the CIMS Expert Work Group were: Henci Goer,, Project Director Mayri Sagay Leslie, MSN, CNM Juith Lothian, PhD, RN, LCCE, FCCE my Romano, MSN, CNM Karen Salt, CCE, M Katherine Shealy, MPH, ICLC, RLC Sharon Storton, M, CCHT, LMFT Deborah Woolley, PhD, CNM, LCCE Ten Steps to aby Frienly Hospital-base breastfeeing promotion interventions can exten uration of exclusive breastfeeing (Lutter, 1997; Merten, 2005). Infants born in facilities that ahere to the aby Frienly Hospital Initiative s (FHI) Ten Steps to Successful reastfeeing are significantly more likely to be breastfeeing at 12 months than those who are not. They are also more likely to be exclusively breastfe at 3 an 6 months an have significantly fewer gastrointestinal tract infections an atopic eczema than those who are not (Kramer, 2001). Similarly, infants born at FHI facilities are more likely to be exclusively breastfe through 5 months of age. Further, birth at such facilities also increases meian uration of any, full, an exclusive breastfeeing. The effects of FHI are stronger for mothers of infants born at facilities that implement FHI more fully (Merten, 2005). ¼ goo Quality ¼ aggregate of quality ratings for iniviual stuies Quantity ¼ magnitue of effect, numbers of stuies, an sample size or power Consistency ¼ the extent to which similar finings are reporte using similar an ifferent stuy esigns Evience Grae INCLUDED STUDIES Kramer, M. S., Chalmers,., Honett, E. D., Sevkovskaya, Z., Dzikovich, I., Shapiro, S., et al. (2001). Promotion of reastfeeing Intervention Trial (PROIT): ranomize trial in the Republic of elarus. The Journal of the merican Meical ssociation, 285(4), Lutter, C., Perez-Escamilla, R., Segal,., Sanghvi, T., Teruya, K., & Wickham, C. (1997). The effectiveness of a hospitalbase program to promote exclusive breast-feeing among low-income women in razil. merican Journal of Public Health, 87, Merten, S., Dratva, J., & ckermann-liebrich, U. (2005). Do baby-frienly hospitals influence breastfeeing uration on a national level? Peiatrics, 116(5), e702 e708. EXCLUDED STUDIES Coutinho,S..,eLira,P.I.,eCarvalhoLima,M.,& shworth,. (2005). Comparison of the effect of two systems for the promotion of exclusive breastfeeing. Lancet, 366(9491), Reason: Not applicable. No non-aby-frienly Hospital Initiative comparison group. Merten, S., & ckermann-liebrich, U. (2004). Exclusive breastfeeing rates an associate factors in Swiss babyfrienly hospitals. Journal of Human Lactation, 20(1), Reason: Poorly esigne. Extensive crossover between groups. 80S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

84 THE COLITION FOR IMPROVING MTERNITY SERVICES: EVIDENCE SIS FOR THE TEN STEPS OF MOTHER-FRIENDLY CRE ppenix: irth Can Safely Take Place at Home an in irthing Centers The Coalition for Improving Maternity Services: Mayri Sagay Leslie, MSN, CNM my Romano, MSN, CNM STRCT lthough most women in the Unite States give birth in hospitals, a substantial boy of research suggests that planne home birth or birth in freestaning birth centers have equally goo or better outcomes for lowrisk women. Out-of-hospital birth often facilitates mother-frienly care. Rationales an systematic reviews of both home birth an freestaning birth center birth are presente. Journal of Perinatal Eucation, 16(1 Supplement), 81S 88S, oi: / X Keywors: home birth, miwives, miwifery, maternal satisfaction, birth center, birthing center, birth center outcomes, birth center transfer, safety an home birth, home birth an outcomes The Coalition for Improving Maternity Services (CIMS) Mother-Frienly Chilbirth Initiative is groune in the principle that birth can safely take place at home an in birthing centers as well as in hospitals. lthough many believe that hospitals are the safest environment for labor an birth, research shows that equally goo or better outcomes can be achieve in low-risk women having planne home births or giving birth in freestaning birth centers. ecause of its inherently noninterventive an more intimate nature, outof-hospital birth facilitates mother-frienly care. HOME IRTH For the purposes of this review, home birth has the following characteristics: woman is at low risk for complications, birth is planne to take place at home, an care provier is qualifie to provie care in the home setting (this will usually be a professional miwife). Stuies of unplanne home births or home birth with no qualifie provier have been exclue. Care in the home birth setting is consistent with mother-frienly care as efine in this ocument. The largest prospective stuy of home births with professional miwives in North merica (54,418) foun the following (Johnson & Daviss, 2005): 92% i not have intravenous fluis uring labor (see Step 6 on pp. 32S 64S), 90% ha fetal heart rate monitoring via intermittent auscultation (Doppler or fetoscope) instea of continuous electronic monitoring (see Step 6), For a escription an iscussion of the methos use to etermine the evience basis of the Ten Steps of Mother-Frienly Care, see this issue s Methos article by Henci Goer on pages 5S 9S. For more information on the Coalition for Improving Maternity Services (CIMS) an copies of the Mother- Frienly Chilbirth Initiative an accompanying Ten Steps of Mother-Frienly Care, log on to the organization s Web site ( org) or call CIMS toll-free at ppenix Leslie & Romano 81S

85 Members of the CIMS Expert Work Group were: Henci Goer,, Project Director Mayri Sagay Leslie, MSN, CNM Juith Lothian, PhD, RN, LCCE, FCCE my Romano, MSN, CNM Karen Salt, CCE, M Katherine Shealy, MPH, ICLC, RLC Sharon Storton, M, CCHT, LMFT Deborah Woolley, PhD, CNM, LCCE 90% achieve spontaneous labor (see Step 6), 2% ha an episiotomy (see Step 6), an 3.7% ha a cesarean section (see Step 6). Home irth Compare with a similar population of women having hospital births, planne home births with a qualifie attenant resulte in the following maternal outcomes (incluing mothers who intene to give birth at home at the onset of labor but were transferre to the hospital at some time uring or after labor): similar rates of antepartum an/or intrapartum hypertension (PIH, pre-eclampsia) (ckermann- Liebrich, 1996; Wiegers, 1996). fewer or similar rates of inuction of labor (Janssen, 2002; Johnson, 2005; Olsen, 1997; Weigers, 1996). fewer or similar rates of augmentation of labor (Janssen, 2002; Johnson, 2005; Olsen, 1997; Weigers, 1996). lower incience of active phase arrest of labor in multiparous women (cessation of progress in cervical ilation after 3 4 cm in women with prior births) (Wiegers, 1996). Evience Grae less use of intravenous fluis in labor (see also Step 6, p. 34S) (Johnson, 2005). N* less use of amniotomy in labor (see also Step 6, p. 38S) (Janssen, 2002; Johnson, 2005). similar incience of abnormal fetal heart rate in labor (Wiegers, 1996; Woocock, 1994). less use of continuous electronic fetal monitoring (external an internal) (Janssen, 2002; Johnson, 2005). increase choice of movement an birth position in labor (see also Step 4, pp. 24S 26S) (ckermann-liebrich, 1996). less nee for analgesia in labor (ckermann-liebrich, 1996; Janssen, 2002). less nee for epiural an/or spinal anesthesia in labor (Janssen, 2002; Johnson, 2005). fewer vaginal instrumental eliveries (vacuum extraction an forceps) (Janssen, 2002; Johnson, 2005; Olsen, 1997). fewer cesarean sections as follows: s fewer or equivalent cesareans (Janssen, 2002; Johnson, 2005; Olsen, 1997; Wiegers, 1996). (Continue ) C N* N* 82S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

86 (Continue) Home irth Evience Grae s fewer cesareans in nulliparous women (Janssen, 2002). N* s fewer cesareans in multiparous women (Janssen, 2002). N* s s fewer cesareans in women who have ha a cesarean before (more vaginal births after cesarean) (Janssen, 2002). fewer cesareans for labor progress isorers (labor ystocia, failure to progress, cephalopelvic isproportion, arrest of labor) (Janssen, 2002). s fewer or equivalent cesareans for emergencies in labor, such as fetal istress (Janssen, 2002; Woocock, 1994). fewer perineal injuries as measure by: s more intact perineums (ckermann-liebrich, 1996; Janssen, 2002). s fewer episiotomies (Janssen, 2002; Johnson, 2005; Olsen, 1997; Wiegers 1996). s fewer or similar rates of anal sphincter laceration (Olsen, 1997; Wiegers, 1996). reuce nee for maternal bloo transfusion (Wiegers, 1996). N* less or equivalent incience of maternal infection or nee for antibiotics after birth (Janssen, 2002; Wiegers, 1996). mong women having a home birth after a hospital birth, 85% sai they preferre the home birth experience an, of those planning more chilren, 91% sai they woul plan a home birth (Davies, 1996). Compare with similar women having hospital births, planne home births with a qualifie attenant resulte in the following perinatal outcomes: similar percentages of low-birth-weight infants (ckermann-liebrich, 1996; Janssen, 2002; Wiegers, 1996). similar rates of infants amitte to intensive care units (Wiegers, 1996). N* less or similar rate of birth traumas (Duran, 1992; Wiegers, 1996; Woocock 1994). similar perinatal mortality rates for infants born to low-risk mothers planning homebirths (Gulbransen, 1997; Janssen, 2002; Olsen 1997). N* N* N* (Continue ) ppenix Leslie & Romano 83S

87 (Continue) Home irth increase incience of neonatal aciemia in home-born infants compare with hospital-born infants. (ckermann-liebrich, 1996). However, evaluation by neutral peiatricians between ay 2 an ay 6 of life showe no ifferences between home- an hospital-born infants. Stuy authors explaine that lower bloo ph measurements are probably an artifact arising from the common practice of elaye cor clamping at home births an the aitional time neee to transport bloo samples to the hospital for analysis. ¼ goo; ¼ fair; C ¼ weak; N ¼ not applicable; PIH ¼ pregnancy-inuce hypertension Quality ¼ aggregate of quality ratings for iniviual stuies Quantity ¼ magnitue of effect, numbers of stuies, an sample size or power Consistency ¼ the extent to which similar finings are reporte using similar an ifferent stuy esigns *only one stuy Evience Grae N* REFERENCE Johnson, K. C., & Daviss,.. (2005). Outcomes of planne home births with certifie professional miwives: Large prospective stuy in North merica. MJ, 330 (7505), INCLUDED STUDIES ckermann-liebrich, U., Voegeli, T., Gunter-Witt, K., Kunz, I., Zullig, M., Schinler, C., et al. (1996). Home versus hospital eliveries: Follow up stuy of matche pairs for proceures an outcome. Zurich Stuy Team. MJ, 313(7068), Davies, J., Hey, E., Rei, W., & Young, G. (1996). Prospective regional stuy of planne home births. Home irth Stuy Steering Group. MJ, 313(7068), Duran,. M. (1992). The safety of home birth: The farm stuy. merican Journal of Public Health, 82(3), Gulbransen, G., Hilton, J., McKay, L., & Cox,. (1997). Home birth in New Zealan : Incience an mortality. The New Zealan Meical Journal, 110(1040), Janssen, P.., Lee, S. K., Ryan, E. M., Etches, D. J., Farquharson, D. F., Peacock, D., et al. (2002). Outcomes of planne home births versus planne hospital births after regulation of miwifery in ritish Columbia. Canaian Meical ssociation Journal, 166(3), Johnson, K. C., & Daviss,.. (2005). Outcomes of planne home births with certifie professional miwives: Large prospective stuy in North merica. MJ, 330(7505), Olsen, O. (1997). Meta-analysis of the safety of home birth. irth, 24(1), 4 13; iscussion 4 6. Wiegers, T.., Keirse, M. J., van er Zee, J., & ergh, G.. H. (1996). Outcome of planne home an planne hospital births in low risk pregnancies: Prospective stuy in miwifery practices in the Netherlans. MJ, 313(7068), Woocock, H. C., Rea,. W., ower, C., Stanley, F. J., & Moore, D. J. (1994). matche cohort stuy of planne home an hospital births in Western ustralia Miwifery, 10(3), EXCLUDED STUDIES nerson, R. E., & Murphy, P.. (1995). Outcomes of 11,788 planne home births attene by certifie nurse-miwives. retrospective escriptive stuy. Journal of Nurse-Miwifery, 40(6), Reason: Ha better quality, more recent research; no comparative ata inclue. astian, H., Keirse, M. J., & Lancaster, P.. (1998). Perinatal eath associate with planne home birth in ustralia: Population base stuy. MJ, 317(7155), Reason: Poor stuy esign. Population inclues high-risk mothers (twins, intra-uterine growth retaration, preterm, breech) an outcomes not ajuste for these factors. Murphy, P.., & Fullerton, J. (1998). Outcomes of intene home births in nurse-miwifery practice: prospective escriptive stuy. Obstetrics an Gynecology, 92(3), Reason: Not applicable. Lacks comparative analysis with hospital outcomes. Pang, J. W., Heffelfinger, J. D., Huang, G. J., eneetti, T. J., & Weiss, N. S. (2002). Outcomes of planne home births in Washington state: Obstetrics an Gynecology, 100(2), Reason: Poorly esigne. Quality of stuy poor enough to invaliate results for the following reasons: inclues unplanne an possibly unattene home births; inclues unplanne home births with unqualifie attenants; inclues preterm births; although it reports a high perinatal mortality, 10 of the 20 babies who ie ha congenital heart isease; some home births may have been chosen with the parents knowing the prognosis; an selection criteria of home births stuie never establishe. 84S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

88 FREESTNDING IRTH CENTERS For the purposes of this ocument, birth centers are efine as freestaning facilities that provie intrapartum an immeiate postpartum care to low-risk women an their newborns. Stuies of hospital-base birth centers were exclue for two reasons. The first reason is that freestaning birth centers provie a largely homogenous style of care aligne with the mother-frienly moel (Rooks, 1992a, 1992b). For birth centers locate within hospitals, the style of care an practice policies can vary greatly from one center to another an from that typical in freestaning birth centers, epening on the hospital s moel of care an its influence on the birth center. The secon reason is that a freestaning birth center s care involves the nee to transfer women an/or babies to the hospital when inicate an important ifference from inhospital care. Freestaning irth Centers The National irth Center Stuy (Rooks, 1992a, 1992b) evaluate the care an outcomes of 11,814 women amitte in labor at 84 birth centers an foun the following practice patterns: 41% ha nonclear fluis or soli foo uring labor (see Step 6 on pp. 32S 64S). 80% i not have intravenous fluis uring labor (see Step 6 on pp. 32S 64S). 90% ha fetal heart rate monitoring via intermittent auscultation (Doppler or fetoscope) instea of continuous electronic monitoring (see Step 6 on pp. 32S 64S). 49% use hyrotherapy (22% tub, 27% shower) (see Step 7 on pp. 65S 73S). 35% were given massages in labor (see Step 7 on pp. 65S 73S). 13% chose to use systemic analgesia (see Step 7 on pp. 65S 73S). 3% chose to have epiural analgesia (see Step 7 on pp. 65S 73S). 79% gave birth in nonsupine positions (see Step 4 on pp. 25S 27S). 90% initiate breastfeeing (see Step 10 on pp. 79S 80S). irth center care results in a cesarean section rate (4.4%) significantly lower than national outcomes reporte for the same time perio (Rooks, 1992b). irth center care results in a perinatal mortality rate (1.3 per 1,000 births overall; 0.7 per 1,000 births excluing congenital anomalies) significantly lower than national outcomes reporte for the same time perio (Rooks, 1992b). When compare with similar populations, care in freestaning birth centers resulte in the following maternal outcomes: similar antepartum hospital amission rates (Jackson, 2003 merican Journal of Public Health [JPH]). Evience Grae N* N* N* fewer inuctions of labor (see also Step 6, pp. 42S 44S) (Jackson, 2003 JPH). N* less frequent oxytocin augmentation of labor (Jackson, 2003 JPH). N* increase intake of foo an rink in labor (Jackson, 2003 JPH). N* increase use of ambulation in labor (see also Step 4, p. 24S) (Jackson, 2003 JPH). N* less frequent use of intravenous fluis in labor (see also Step 6, p. 34S) (Fullerton, 1992; Jackson, 2003 JPH). N* (Continue ) ppenix Leslie & Romano 85S

89 (Continue) Freestaning irth Centers Evience Grae less use of amniotomy in labor (see also Step 6, p. 38S) (Fullerton, 1992; Jackson, 2003 JPH). fewer episoes of abnormal fetal heart rate in labor (Fullerton, 1992; Jackson, 2003 JPH). less use of continuous electronic fetal monitoring (external an internal) (see also Step 6, p. 39S) (Fullerton, 1992; Jackson, 2003 JPH). more effective pain management in labor, incluing: s less frequent use of analgesia in labor (Fullerton, 1992; Jackson, 2003 JPH). s less frequent use of epiural anesthesia in labor (Fullerton, 1992; Jackson, 2003 JPH). s more use of nonpharmacological pain relief measures in labor, incluing hyrotherapy, comfort measures, an other strategies (see also Step 7, pp. 65S 68S) (Fullerton, 1992; Jackson, 2003 JPH). increase number of spontaneous vaginal births (Davi, 1999; Jackson, 2003 JPH; Walsh, 2004). fewer vaginal instrumental eliveries (vacuum extraction an forceps) (Davi, 1999; Jackson, 2003 JPH). fewer cesarean rates overall (Davi, 1999; Jackson, 2003 JPH; Walsh, 2004). fewer episiotomies (Fullerton, 1992; Jackson, JPH 2003; Walsh, 2004). similar incience of maternal infection or nee for antibiotics after birth when compare with hospital births (Jackson, 2003 JPH). No stuy foun an increase in the infection rate with birth center care. When compare with similar populations planning hospital births, care in freestaning birth centers resulte in the following perinatal outcomes: similar rates of preterm births (Jackson, 2003 JPH). N* similar rates of low birth-weight infants (Davi, 1999; Fullerton, 1992; Jackson, 2003 JPH). similar incience of thick meconium in the amniotic flui (Fullerton, 1992; Jackson, 2003 JPH). lower incience of fetal heart rate abnormalities (Fullerton, 1992; Jackson, 2003). (Continue ) N* N* 86S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

90 (Continue) Freestaning irth Centers similar rates of infants being amitte to intensive care units after birth (Davi, 1999; Jackson, 2003 JPH). Evience Grae fewer infants requiring evaluation an treatment for infection (Jackson, 2003 JPH). N (only 1 stuy) similar incience of neonatal reamission (Jackson, 2003 JPH). N* Women elivering in birth centers reporte that, compare with their prior experiences in hospitals, birth center staff (Coyle, 2000): treate pregnancy an birth as a natural life event; treate women as autonomous iniviuals an provie them with information that enable them to make informe ecisions; actively encourage women to listen to their boies an trust their ability to give birth naturally; ha a noninterventionist approach to care; an supporte the mother s own belief in the normalcy of birth. ¼ goo; ¼ fair; N ¼ not applicable Quality ¼ aggregate of quality ratings for iniviual stuies Quantity ¼ magnitue of effect, numbers of stuies, an sample size or power Consistency ¼ the extent to which similar finings are reporte using similar an ifferent stuy esigns *only one stuy N* REFERENCES Rooks, J. P., Weatherby, N. L., & Ernst, E. K. (1992a). The National irth Center Stuy. Part II Intrapartum an immeiate postpartum an neonatal care. Journal of Nurse-Miwifery, 37(5), Rooks, J. P., Weatherby, N. L., & Ernst, E. K. (1992b). The National irth Center Stuy. Part III Intrapartum an immeiate postpartum an neonatal complications an transfers, postpartum an neonatal care, outcomes, an client satisfaction. Journal of Nurse- Miwifery, 37(6), INCLUDED STUDIES Coyle, K. L., Hauck, Y., Percival, P., & Kristjanson, L. J. (2001). Normality an collaboration: Mothers perceptions of birth centre versus hospital care. Miwifery, 17(3), Davi, M., von Schwarzenfel, H. K., Dimer, J.., & Kentenich, H. (1999). Perinatal outcome in hospital an birth center obstetric care. International Journal of Gynaecology an Obstetrics, 65(2), Fullerton, J. T., & Severino, R. (1992). In-hospital care for low-risk chilbirth. Comparison with results from the National irth Center Stuy. Journal of Nurse- Miwifery, 37(5), Jackson, D. J., Lang, J. M., Swartz, W. H., Ganiats, T. G., Fullerton, J., Ecker, J., et al. (2003). Outcomes, safety, an resource utilization in a collaborative care birth center program compare with traitional physicianbase perinatal care. merican Journal of Public Health, 93(6), Rooks, J. P., Weatherby, N. L., & Ernst, E. K. (1992a). The National irth Center Stuy. Part II Intrapartum an immeiate postpartum an neonatal care. Journal of Nurse-Miwifery, 37(5), Rooks, J. P., Weatherby, N. L., & Ernst, E. K. (1992b). The National irth Center Stuy. Part III Intrapartum an immeiate postpartum an neonatal complications an transfers, postpartum an neonatal care, outcomes, an client satisfaction. Journal of Nurse- Miwifery, 37(6), Walsh, D., & Downe, S. M. (2004). Outcomes of freestaning, miwife-le birth centers: structure review. irth, 31(3), EXCLUDED STUDIES Gottvall, K., Grunewal, C., & Walenstrom, U. (2004). Safety of birth centre care: perinatal mortality over a 10-year perio. JOG, 111(1), Reason: Not applicable. irth center locate within ahospital. Schmit, N., belsen,., & Oian, P. (2002). Deliveries in maternity homes in Norway: Results from a 2-year prospective stuy. cta obstetricia et Gynecologica Scaninavica, 81(8), Reason: No ata for comparison to similar population. lso, geographical obstacles require 2 3 hours for transport; not generalizable to other locations. ppenix Leslie & Romano 87S

91 Swartz, W., Jackson, D., Lang, J., Ecker, J., Ganiats, T., Dickinson, C., et al. (1998). The irthplace collaborative practice moel: Results from the San Diego irth Center Stuy. Primary Care Upate for Ob/Gyns, 5(4), 207. Reason: Data inclue in Jackson (2003). Walenstrom, U., & Nilsson, C.. (1997). ranomize controlle stuy of birth center care versus stanar maternity care: Effects on women s health. irth, 24(1), Reason: Not applicable. irth center locate within a hospital. Walenstrom, U., Nilsson, C.., & Winblah,. (1997). The Stockholm birth centre trial: Maternal an infant outcome. ritish Journal of Obstetrics an Gynaecology, 104(4), Reason: Not applicable. irth center locate within a hospital. MYRI SGDY LESLIE is a faculty member in the School of Nursing at Georgetown University in Washington, DC. She is also a member of the CIMS Leaership Team. MY ROMNO complete her nurse miwifery training at Yale University School of Nursing an has practice in a birth center an in the home setting. She is currently a resient expert an the Web site eitor of the Lamaze Institute for Normal irth ( 88S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

92 THE COLITION FOR IMPROVING MTERNITY SERVICES: EVIDENCE SIS FOR THE TEN STEPS OF MOTHER-FRIENDLY CRE Discussion The Coalition for Improving Maternity Services: Juith. Lothian, PhD, RN, LCCE, FCCE STRCT The Ten Steps of Mother-Frienly Care evelope by the Coalition for Improving Maternity Services (CIMS) provies guielines for caregivers, hospitals, birth centers, an home birth services that are committe to ensuring their services are mother-frienly. The evience basis compile by the CIMS Expert Work Group for the Ten Steps of Mother-Frienly Care confirms that substantial support exists for the Ten Steps. Furthermore, the group s finings along with the results from the Listening to Mothers II survey support the relevance an continue importance of the Ten Steps, as well as the larger CIMS Mother-Frienly Chilbirth Initiative, an suggest future irection for researchers, maternity caregivers, an chilbearing women. Suggestions for ongoing research an effective avocacy on behalf of mother-frienly care practices are encourage. Journal of Perinatal Eucation, 16(1 Supplement), 89S 92S, oi: / X Keywors: The Coalition for Improving Maternity Services, Mother-Frienly Chilbirth Initiative, Ten Steps of Mother- Frienly Care, normal birth In setting out on this project, the goal of the Coalition for Improving Maternity Services (CIMS) Expert Work Group was to provie evience to support the Ten Steps of Mother-Frienly Care that woul be concise, precise, an wiely available to the birth community miwives, physicians, nurses, chilbirth eucators, oulas, hospital aministrators, an chilbearing women. The group has accomplishe its goal. The report presente in this publication confirms that substantial support exists for the Ten Steps of Mother-Frienly Care. The CIMS Expert Work Group s systematic review of the research publishe in the ecae since the Ten Steps of Mother-Frienly Care was evelope an launche provies compelling evience for each of the Ten Steps. The systematic review of out-of-hospital birth is a significant contribution to the literature. The transparency of the group s methos (see pp. 5S 9S of this issue) an its willingness to evaluate evience relate to no evience of benefit or no evience of harm have resulte in a more allencompassing an meaningful review of the evience than many systematic reviews. The CIMS Expert Work Group s finings confirm the relevance an continue importance of the Ten Steps of Mother-Frienly Care, aswellasthelarger Mother-Frienly Chilbirth Initiative (CIMS, 1996), an suggest future irection for researchers, maternity caregivers, an chilbearing women. It also For more information on the Coalition for Improving Maternity Services (CIMS) an copies of the Mother- Frienly Chilbirth Initiative an accompanying Ten Steps of Mother-Frienly Care, log on to the organization s Web site ( or call CIMS toll-free at This project was mae possible by a generous grant from a onor s avise fun of the New Hampshire Charitable Founation. Discussion Lothian 89S

93 Members of the CIMS Expert Work Group an supporting associates were: Henci Goer,, Project Director Mayri Sagay Leslie, MSN, CNM Juith Lothian, PhD, RN, LCCE, FCCE my Romano, MSN, CNM Karen Salt, CCE, M Katherine Shealy, MPH, ICLC, RLC Sharon Storton, M, CCHT, LMFT Deborah Woolley, PhD, CNM, LCCE Nicette Jukelevics, M, ICCE, CIMS Leaership Team Liason llana Moore,, Project ssistant Ranall Wallach,, M, Meical Eitor For a copy of the Listening to Mothers II survey, call Chilbirth Connection (formerly Maternity Center ssociation) at or visit the organization s Web site (www. chilbirthconnection.org). raises the issue: Why, with this much support, has birth become more, rather than less, motherfrienly? RESULTS OF THE LISTENING TO MOTHERS II SURVEY The completion of the research presente here coincie with the publication of Listening to Mothers II: Report of the Secon National U.S. Survey of Women s Chilbearing Experience (Declercq, Sakala, Corry, & pplebaum, 2006). Listening to Mothers II was carrie out by Chilbirth Connection (formerly Maternity Center ssociation), in collaboration with Lamaze International, an was conucte by Harris Interactive, a market research company. The sample inclue a total of 1,573 women between the ages of 18 an 44 with a singleton birth in a Unite States hospital in There were 1,373 online participants an 200 telephone participants. The finings of Listening to Mothers II confirm that birth is increasingly intervention intensive an less mother-frienly (Declercq et al., 2006). Of the surveye women who ha vaginal births, 80% ha intravenous lines, an 55% ha their labors augmente with pitocin. Ninety-four percent of the women ha electronic fetal monitoring (93% of those women were monitore continuously). Only 15% of the women reporte eating anything in labor, an only 40% reporte that they ha anything to rink. The cesarean rate among the surveye women was 33%, with half primary an half repeat surgeries. Most repeat cesareans were planne. The vaginal birth after cesarean (VC) rate was 11%. Eighty-nine percent of the women who have ha a previous cesarean ha a repeat cesarean. lthough 45% of the women who have ha a previous cesarean were intereste in VC, 57% of them were enie that option. The unwillingness of the caregiver (47%) or hospital (26%) was the main reason reporte as the basis for the enial. Forty-one percent of the responents reporte that their caregiver trie to inuce labor; 84% of the time, this was successful. Only 1% of the women gave birth outsie the hospital; less than 10% receive care provie by miwives, an 3% were attene by a oula or professional labor attenant. significant proportion (86%) of the responents use pain meication. mong the women having a vaginal birth, 71% receive an epiural. Less than half of the women use nonpharmacological pain relief in labor: 49%, breathing; 42%, position change or movement; 25%, mental strategies such as relaxation, visualization, or hypnosis; an 29%, hans-on techniques such as massage, touch, or acupressure. Only 6% of the women reporte using immersion in a tub uring labor, an only 4% use showers. quarter of the women reporte walking after they were amitte to the hospital in labor, an 57% reporte they were on their backs uring pushing, with another 35% pushing in a semisitting position. The women reporte they wante full, complete information about their choices. Eighty-one percent sai they thought it necessary to know every complication associate with an intervention, an another 19% thought it important to know most complications. Most women were unsure of the averse effects of interventions. Even those who actually experience the intervention were unable to ientify averse effects of cesarean an inuction. Only 11% of the women refuse to accept care that was offere to them. Only one thir of babies were in their mothers arms immeiately after birth. lthough 61% sai they wante to breastfee exclusively, at one week only 52% were oing so. abies of nearly half the mothers who intene to breastfee were given formula or water supplements an a pacifier, an most of the mothers receive formula samples or offers. Sixty-six percent of the women reporte suffering some egree of epressive symptoms that woul suggest a nee for follow-up measures, but only 20% of these women consulte a health-care or mental health professional. The Listening to Mothers II survey results confirm that stanar maternity care in the Unite States is far from mother-frienly an provies further support that each of the steps of the Ten Steps of Mother-Frienly Care continue to be relevant. ONGOING NEED FOR RESERCH ND DVOCCY Why has the substantial boy of research support for the Ten Steps of Mother-Frienly Care faile to create change in maternity care? Where o we go from here? Our suggestions fall into two, broa, equally important categories: research an avocacy. Research There are two unerlying issues of concern relate to research: factors that influence what oes an 90S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

94 oes not get stuie, an the failure to change practice base on best evience. oth issues have implications for mother-frienly care. The ominant meical moel of care exerts a powerful influence on what gets stuie an what oes not. The result is a scarcity of evience to establish the benefit of many nonmeical measures that facilitate normal, physiological labor an birth an help women manage their labors. The systematic review points out the gaps in these areas. further problem is that the current stanar emans conclusive proof of benefit before implementing change in practice relate to nonmeical issues; however, no such emans are mae for changing practices that show no benefit but are consistent with meical values. Two examples illustrate this point. First, no evience shows any benefit for continue routine use of either intravenous fluis or continuous electronic fetal monitoring, although harm has been emonstrate for both. Secon, in contrast, the freeom to walk uring labor has not been shown to have a major effect on labor progress, but when given the choice women prefer it. In spite of the preferre choice, women continue to be confine to be in labor. critical nee exists for an in-epth analysis of why this is so an for a more complete unerstaning of the barriers to change. What is the most appropriate way to evaluate maternity care practices? In 2001, Murphy an Fullerton propose using an optimality moel to evaluate miwifery care an, then, suggeste its value in evaluating maternity care. Optimality looks for the esire, best possible outcome rather than the occurrence of unesire, averse (an often rare) events. Optimality replaces the focus on risk an averse outcomes with a focus on measuring the frequency of optimal (goo, esire) outcomes. This approach allows for the incorporation of a noninterventive philosophy in the moel. The optimality moel provies an appropriate framework for esigning a stuy of mother-frienly care. We think it is time for a large-scale stuy of mother-frienly care compare to stanar maternity care measuring optimal outcomes rather than just averse effects. For women, the birth environment an caregiver exert powerful influences on how their chilbearing experience unfols. The Ten Steps of Mother- Frienly Care along with Having a aby? Ten Questions to sk (CIMS, 2000), which is base on the Ten Steps provie guielines for women as they attempt to untangle the web of moern obstetrics an make important ecisions about their care an the birth of their babies. The Ten Steps of Mother-Frienly Care provies guielines for caregivers, hospitals, birth centers, an home birth services that are committe to ensuring their services are mother-frienly. ut these guielines are only a first step. Ultimately, informe ecision making must inclue the ability an the power to either consent or refuse specific care practices. Women nee a eeper unerstaning of their right to informe refusal, especially in areas whereby isagreement occurs over what constitutes best practice. Informe refusal has the potential to exert pressure on a maternity care system that is resistant to change. The CIMS is eveloping criteria for the esignation of birth sites as mother-frienly. itionally, grassroots organizations are working with CIMS to rate how mother-frienly iniviual care proviers an hospitals actually are an, then, making this information wiely available. The Institute of Meicine (2001) has this to say in its publication, Crossing the Quality Chasm: Care must be elivere by systems that are carefully an consciously esigne to provie care that is safe, effective, patient-centere, timely, efficient an equitable. Such systems must be esigne to serve the nees of patients, an to ensure that they are fully informe, retain control an participate in care elivery whenever possible, an receive care that is respectful of their values an preferences. (p. 36) The evience-base Ten Steps of Mother-Frienly Care is an important resource in helping that happen an in ultimately improving maternity care in the Unite States an globally. Having a aby? Ten Questions to sk is available online at the following link to the Coalition for Improving Maternity Services s Web site: / resources/10q/ vocacy vocates can use this systematic review to avance the principles of the Mother-Frienly Chilbirth Initiative an the Ten Steps of Mother-Frienly Care. REFERENCES Coalition for Improving Maternity Services. (1996). The mother-frienly chilbirth initiative. Retrieve December 9, 2006, from MFCI/steps Discussion Lothian 91S

95 Coalition for Improving Maternity Services. (2000). Having a aby? Ten questions to ask. Retrieve December 14, 2006, from resources/10q/ Declercq, E., Sakala, C., Corry, M., & pplebaum, S. (2006). Listening to mothers II: Report of the secon national U.S. survey of women s chilbearing experiences. New York: Chilbirth Connection. Institute of Meicine. (2001). Crossing the quality chasm: new health system for the 21st century. Washington, D.C.: National caemy Press. Murphy, P.., & Fullerton, J. T. (2001). Measuring outcomes of miwifery care: Development of an instrument to assess optimality. Journal of Miwifery & Women s Health, 46(5), JUDITH LOTHIN is a chilbirth eucator in rooklyn, New York, a member of the Lamaze International oar of Directors, an the associate eitor of The Journal of Perinatal Eucation. She is also an associate professor in the College of Nursing at Seton Hall University in South Orange, New Jersey. 92S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

96 THE COLITION FOR IMPROVING MTERNITY SERVICES: EVIDENCE SIS FOR THE TEN STEPS OF MOTHER-FRIENDLY CRE Commentary The Coalition for Improving Maternity Services: Susan Hoges, MS Sanra itonti Stewart arbara Hotelling, MSN, CD (DON), LCCE, FCCE my Romano, MSN, CNM STRCT consumer avocate, two chilbirth eucators, an a certifie nurse-miwife each provie commentary on the effectiveness of an potential uses for the Evience asis for the Ten Steps of Mother-Frienly Care. Journal of Perinatal Eucation, 16(1 Supplement), 93S 96S, oi: / X Keywors: The Coalition for Improving Maternity Services, Mother-Frienly Chilbirth Initiative, Ten Steps of Mother- Frienly Care, normal birth, chilbirth eucation, miwifery moel of care POWERFUL RESOURCE FOR MOTHERS, DVOCTES, HELTH-CRE PROVIDERS Evience asis for the Ten Steps of Mother-Frienly Care will be a tremenous resource for mothers an avocates of normal birth everywhere. To have all of the current evience collecte in one place, publishe in a recognize journal, an organize by the Ten Steps will be useful for many purposes. Consumer avocates for normal birth likely will be involve in bringing this evience to the attention of legislators an members of state agencies regaring legislation an/or rules an regulations for hospitals, birth centers, an miwives. Having the evience in han will strengthen the role avocates can play in these government processes. unique feature of the Evience asis for the Ten Steps of Mother-Frienly Care is the explanations for inclusion an exclusion of specific stuies. Few iniviuals have the time an expertise to review an assess every stuy on a given topic. y incluing lists of exclue stuies with the reasons for exclusion, the Expert Work Group of the Coalition for Improving Maternity Services (CIMS), who o have this expertise, have given us a resource for refuting erroneous conclusions or assertions that are base on ba science when it comes to maternity care. Each of the steps is important, but perhaps one of the most useful will be the article on Step 6, which aresses the evience concerning a list of interventions that are routine or common in most hospital-base maternity care (see pp. 32S 64S). The article will be useful for helping women to unerstan the lack of evience or contrary evience regaring many common hospital an obstetric practices. lthough this kin of information will be useful in persuaing hospitals to move towar being mother-frienly, the evience can also be use by mothers to support informe refusal of unnecessary proceures an interventions, leaing to a more mother-frienly birth experience. For more information on the Coalition for Improving Maternity Services (CIMS) an copies of the Mother-Frienly Chilbirth Initiative an accompanying Ten Steps of Mother-Frienly Care, log on to the organization s Web site (www. motherfrienly.org) or call CIMS toll-free at Commentary Hoges, Stewart, Hotelling, & Romano 93S

97 Members of the CIMS Expert Work Group were: Henci Goer,, Project Director Mayri Sagay Leslie, MSN, CNM Juith Lothian, PhD, RN, LCCE, FCCE my Romano, MSN, CNM Karen Salt, CCE, M Katherine Shealy, MPH, ICLC, RLC Sharon Storton, M, CCHT, LMFT Deborah Woolley, PhD, CNM, LCCE Citizens for Miwifery is a national consumer-base group promoting the Miwives Moel of Care. For more information, call tollfree at or visit the organization s Web site ( irthnetwork National is a national consumer-base organization supporting the work of local chapters to promote the Coalition for Improving Maternity Service s Mother-Frienly Chilbirth Initiative. For more information, call toll-free at IRTH or visit the organization s Web site ( nother useful resource will be the evience for Step 1 (see pp. 10S 19S). This step ensures that women have access to a wie variety of support in labor an uring the pregnancy an postpartum perios: unrestricte access to birth companions of their choice, incluing family an friens; unrestricte access to continuous emotional an physical support from a skille woman such as a oula; an access to miwifery care. The extensive rationale emonstrates the benefits of miwifery care in any setting an will len strong support for increasing access to miwives an the Miwives Moel of Care in an out of hospitals. Existing government resources, such as the Consumer ill of Rights an Responsibilities an the Conitions of Participation (for hospitals to participate in Meicai), require that care be appropriate ; reiterate that patients shoul be provie complete information about meical tests, treatments, an proceures; an reiterate their right to consent to or refuse these. The evience presente for Step 1 in the Evience asis for the Ten Steps of Mother-Frienly Care will be invaluable as we learn to make use of these government resources for iniviual situations (one woman at a time) an for our work in affecting changes in maternity care at the hospital level. The evience project will also be a powerful support for the Transparency in Maternity Care project of CIMS. This project will inclue pulling together all of the maternity care intervention rates, annually, for hospitals an birth centers nationwie an making them available on the Internet. To better help consumers utilize this information an evaluate their local institutions, the results of the Evience asis for the Ten Steps of Mother-Frienly Care coul be presente alongsie each of the hospital s intervention rates. irthnetwork National chapter leaers an volunteers plan to use the materials to create a presentation for college-level women s stuies an nursing stuents. t the local level, irthnetwork National chapters an other grassroots avocacy organizations will use the information in Evience asis for the Ten Steps of Mother-Frienly Care as they work to inform local hospitals an state health agencies about the CIMS Mother-Frienly Chilbirth Initiative an the Ten Steps. vocates will be able to use the Evience asis for the Ten Steps of Mother-Frienly Care to emonstrate persuasively how the steps are supporte by the evience an are funamental to the o no harm principle of meical care. To facilitate public knowlege about the Evience asis for the Ten Steps of Mother-Frienly Care, Citizens for Miwifery plans to create summary fact sheets that will put the information into terms easily unerstoo by the public. The fact sheets will be freely available on the Citizens for Miwifery Web site for public eucation, chilbirth eucation classes, community meetings an birth circles, an many other programs an events hel by grassroots groups, such as Friens of Miwives organizations an irthnetwork National groups. Summary fact sheets will help get the information to women an families who might not otherwise fin or rea the Evience asis for the Ten Steps of Mother-Frienly Care. Susan Hoges, MS Presient, Citizens for Miwifery Sanra itonti Stewart, chilbirth eucator an cofouner of irth Network National TECHING WITH CONFIDENCE For approximately three ecaes, it has been amazing to me that I a mother, chilbirth eucator, an oula have spent countless ollars an hours attening evience-base conferences, subscribing to evience-base birth journals, an revising my teaching strategies an information to reflect the research. Parents in my classes still report to me that they woul not be given anything but ice chips uring labor an birth, their movements woul be confine to the length of a monitor cor, an only two people woul be allowe to atten to their emotional an physical nees at birth. These practices have not stoppe in spite of the evience that says routine use of interventions are not helpful an can be harmful. How can it be that practice oes not reflect the evience? Why is it important for me to continue examining the research if it will not be applie at the birth? eing the low woman on the totem pole in the care of care proviers, I absolutely must know that there is evience to back my statements an my actions. s a oula, when I encourage mothers to ask care proviers what foos they shoul not eat instea of what nourishment they can have, I am confient with my knowlege that women choose wisely for themselves what to eat an rink in labor an birth. lso, I have rea the Cochrane systematic reviews that say withholing foo an flui in labor an birth can stall the labor an require more interventions with associate risks. s a chilbirth eucator, I teach this information using the latest ault eucation techniques that I 94S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1

98 have learne to foster retention an maximize use of what I have carefully chosen for parents in my classes. Knowlege of how aults learn information has change over the past three ecaes. I no longer use outlines, vieos, an lectures for most of my teaching; instea, I have foun learning tasks to be more successful. Staying abreast of the research has kept me from proviing inaccurate information. I once istribute practice sheets for breathing techniques an encourage parents to recor every contraction in early labor. reathing techniques now occupy their rightful place as one of many relaxation techniques, an going to the movies or baking cakes uring early labor is now encourage. I once taught with eucators who felt conferences were too expensive to invest in. They taught breathing techniques with a metronome! Practice base on the Frieman curve a reference to the normal uration of each stage base on an anecotal stuy reporte by Emanuel Frieman in 1954 has le to countless, unnecessary interventions because women s labor progress was not ahering to an average base on a small sample in a small hospital. Let s look at the potentially harmful effects of a practice that oes not reflect the research finings. The first goal of Healthy People 2010 is to help iniviuals of all ages increase life expectancy an improve their quality of life. Research tells us that some birth practices, such as separation of healthy mothers an babies after birth, can actually impose lifelong risks to infant health. The infant who is remove from his/her mother oes not have mature temperature-regulating mechanisms. The mother can regulate the baby s temperature with her boy temperature better than the warmers. Her temperature falls in response to a higher temperature in the infant, an her temperature rises when the infant nees more warmth. If the infant is place in the warmer an his/her temperature is inaequate, even more separation happens. The infant has a long, quiet, alert state uring that first hour an also begins nursing. Interfering with nursing can cause problems that the mother has ifficulty overcoming an, so, her infant receives artificial milk, leaving the baby expose to a list of health problems too long to inclue in this commentary. Thus, a simple an evience-base practice of nonseparation of mother an infant after birth without a meical inication can improve the quality an length of a newborn s life, facilitate attachment, an, accoring to Healthy People 2010, improve our society as a whole. The systematic reviews of the Evience asis for the Ten Steps of Mother-Frienly Care are a gift to oulas, eucators, an me. We can teach with confience, irrespective of local practices an hospital policies. We can inform women an men of the evience, where they can fin the evience for future ecision making, an how to speak so that care proviers listen. We can compare the latest an greatest reports of a single research fining that the meia reports in its biase ways with a systematic look at quality research an answer confiently the questions of parents wanting only the best for their chilren. Teaching with confience means having the evience to rely on. arbara Hotelling, MSN, CD (DON), LCCE, FCCE Inepenent chilbirth eucator an oula MIDWIFERY ND EVIDENCE-SED PRCTICE I stumble into miwifery at a time when eviencebase practice was becoming the preominant creo. large an growing boy of research supporte miwifery care, an the fiel of obstetrics was finally coming uner fire for ecaes of proviing ineffective an harmful care to women an babies. It was empowering to be part of a profession that was simultaneously ancient an at the vanguar of evience-base practice. I knew the criticalthinking skills I evelope in my training woul serve me at least as well as my clinical skills. Uner the mentorship of forwar-thinking teachers, I learne to rea an pick apart stuies an built up the chutzpah to challenge my preceptors, nurses, an even some octors when I saw them practicing in a way that was not evience-base. So I entere into clinical practice knowing that the stanar package of maternity care was not supporte by the research. ut with all the stress of launching my career an so many facts an formulas toremember, I i not havethe time orwherewithalto look up the evience for every single practice I objecte to. My mantra That s not evience-base! quickly wore thin without any supporting etails. I sure coul have use a ocument that remine me of the specific harms of, say, routine amniotomy, restricting oral intake, or elective inuction. Evience asis for the Ten Steps of Mother- Frienly Care provies a nuance an robust review of the evience while still being concise an easy to use. The reviewers provie evience-base For more information on Healthy People 2010, a statement of national health objectives in the Unite States, log on to the Healthy People 2010 Web site ( Commentary Hoges, Stewart, Hotelling, & Romano 95S

99 For a escription an iscussion of the methos use to etermine the evience basis of the Ten Steps of Mother-Frienly Care, see this issue s Methos article by Henci Goer on pages 5S 9S. rationales for ahering to each element of motherfrienly care, an they rate the quality, quantity, an consistency of the evience for each rationale. Importantly, they also note when there is no evience of benefit for care practices that are wiesprea (such as routine IVs) an when there is no evience of harm for practices that women prefer but are routinely enie (such as ambulation in labor). The ocument s core message is clear an resouning: If it isrupts the normal process of labor an birth, the mother hasn t aske for it, an no evience supports it, then on t o it! How ifferent this is from the conventional obstetric zeal for the machine that goes ping. It is no coincience that the miwifery moel of care is nearly ientical to the Ten Steps of Mother-Frienly Care. t its best an purest, miwifery care is characterize by the appropriate use of interventions, cultural competency, an attention to the unique nees an concerns of the iniviual woman all key elements of the Ten Steps. Therefore, the Evience asis for the Ten Steps of Mother-Frienly Care becomes an invaluable tool for eveloping miwifery clinical practice stanars an benchmarking goals. Equippe with this succinct an compelling review of the relevant research, miwives can make the case for mother-frienly care to the consulting physicians an practice-privilege-review boar members who often must approve our practice stanars. This ocument will also serve miwifery stuents an apprentices well. Stuent miwives nee to master normal birth before they can move on to managing complications. Together with some han skills an knowlege of birth physiology, the Evience asis for the Ten Steps of Mother-Frienly Care provies that founation. s case-base learning becomes more ingraine in miwifery curricula, stuents will fin greater use for succinct reviews of the evience for miwifery care practices. s stuents then make the final leap into practice, fining the link between the care practice, the rationale, an the evience to support it as it is lai out in this ocument will alreay come naturally. Our new generation of miwives will become practitioners of evience-base care. In the en, of course, miwifery is about proviing optimal, iniviualize care to the chilbearing woman an her family. What makes this ocument so extraorinary is its simultaneous utility both as a philosophical octrine an as clinical practice guielines. It escribes what we o, how we o it, an why we o it. n, most importantly, it acknowleges that we o it with women. my Romano, MSN, CNM Lamaze Institute for Normal irth SUSN HODGES, an activist for miwifery since 1985, is a founer an the current presient of Citizens for Miwifery. She is a member of the US irth Practices Committee of the Coalition for Improving Maternity Services (CIMS), a member of the Consumer Panel of the Cochrane Collaboration s Pregnancy an Chilbirth Group, an a former consumer member of the North merican Registry of Miwives Certification Task Force ( ), which create the Certifie Professional Miwife creential. SNDR ITONTI STEWRT is a chilbirth eucator an cofouner of irth Network National, a grassroots consumer organization working to improve maternity care through the eucation of empowerment of women. She is currently serving as the cochair of the Grassroots vocacy Committee of CIMS, as well as a member of the Governance Committee of CIMS. RR HOTELLING is an inepenent chilbirth eucator an oula in Rochester Hills, Michigan. She has serve as presient of Lamaze International, presient of Doulas of North merica (DON), an chair of CIMS. MY ROMNO complete her nurse-miwifery training at Yale University School of Nursing an has practice in a birth center an in the home setting. She is currently a resient expert an the Web site eitor of the Lamaze Institute for Normal irth ( 96S The Journal of Perinatal Eucation Supplement Winter 2007, Volume 16, Number 1