Family-Centered Maternity Care: Past, Present, Future
by Celeste R. Phillips

Introduction

Throughout history, most social movements have begun in reaction to situations that people perceived to be intolerable at the time. "Family-centered maternity care" (FCMC) is one such social movement. Hospital birth practices of the times generated the impetus for reform. To understand the FCMC social movement, it is important to take a brief look at the evolution of childbirth in America over the past one hundred years.

Home to Hospital

At the beginning of the twentieth century, most women gave birth at home generally attended by midwives and occasionally by a physician. Childbirth was accepted as part of the normal life cycle, and family and friends supported women as they gave birth in the familiar environment where they spent their daily lives (Wertz and Wertz 1989). The woman's family held the locus of control and support. After the birth, family members and friends took care of the house and children for several weeks so the mother could rest and get to know her new baby.

The 1920s

In the second decade of the twentieth century, however, new events changed this scene. Efforts at maternity care quality control resulted in improved medical education and training, and obstetrics/gynecology became recognized as a medical specialty. In the first volume of The American Journal of Obstetrics and Gynecology, Joseph De Lee, MD, wrote of childbirth as a "pathologic process" and urged routine use of forceps, episiotomy, and anesthesia (Speert 1980). Obstetricians were trained to be surgeons and high-risk problem solvers, considering birth from a worst-case perspective. Their training emphasized the task of delivery rather than the process of birth.

During this same time, midwifery in America was suppressed as the modern hospital came into its own and the wonders of science and technology dazzled the population (American Journal of Public Health 1983). The modern antiseptic hospital offered women a medical specialist attendant, safe and painless delivery, and complete care of their newborn in an isolated, well-supervised nursery.

The 1930s

By 1936, approximately one-third of all live births occurred in hospitals, half of all births were delivered by physicians in homes, and midwives accounted for 12 percent of all births (American Journal of Public Health 1983). With popular magazines and leading women of the time encouraging expectant mothers to seek hospitalization for birth, the change to hospital birth was relentless.

The 1940s

By 1945, approximately 80 percent of women delivered in hospitals in surgical settings, under general anesthesia, attended by physicians, and subjected to ritualistic nursing interventions.

Physicians wrote most obstetric nursing texts. In fact, Dr. De Lee authored a nursing text that was popular in nursing schools for more than twenty years. For nursing education, he emphasized that, "Labor and its complications have the highest pathologic dignity and require the care and attention of the most skillful surgeon and the most efficient nurses." Throughout his text, Dr. De Lee emphasized the importance of aseptic technique and nursing's control over the environment for birth (De Lee 1927).

In actual hospital practice, nurses chose a subspecialty area in which to work, which included normal newborn nursery, labor and delivery, or postpartum. Rigid rules and regulations were established so nurses practiced "constant watchfulness" (De Lee 1927) over mother and baby, excluding family and friends except for limited periods of time.

Women were given "twilight sleep" (morphine and scopolamine) for pain relief during labor. Due to scopolamine's amnesiac effect, women seldom remembered their labor experiences, which may have been a good thing at the time. Because they labored alone in narrow, windowless labor rooms, were transferred to surgical-style delivery rooms for birth under general anesthesia, and were moved to recovery rooms for the first hours after birth, it may have been a good thing for women not to remember their birth experiences.

After the babies were born, babies and mothers were separated; babies routinely were sent to large central nurseries and brought to their mothers for twenty-minute feeding periods scheduled every three to four hours. Mothers commonly bottle-fed their babies with modern "scientific" formula (Apple 1987).

Hospital policies restricted visitation and participation of families and friends, who were seen as sources of infection (Wooden and Engel 1965; Leavitt 1989). Women remained in the hospital, housed in postpartum wards for seven to ten days where, separated from their families, they often felt lonely and isolated (Leavitt 1989). Thus the mother had an impersonal assembly-line experience and was then separated from her baby, and the father remained excluded.

Rooming-In

The detrimental psychological implications of separating mothers and babies did not go unrecognized. Yale pediatrician Dr. Gesell and his colleague, Dr. Frances Ilg, began writing about the importance of early contact between infants and their mothers and the need for a self-regulatory program of care for newborns during their first days of life. They coined the term "rooming-in," which referred to a hospital arrangement of keeping the newborn at the mother's bedside and allowing the mother to take as much care of the baby as she wished (Gesell and Ilg 1943). Dr. Edith Jackson developed this arrangement at Grace New Haven Community Hospital in October 1946 (Thoms 1950; Dharamraj et al. 1981).

In 1948, Woman's Day, a popular women's magazine, published an article titled "Whose Baby Is It?" (Ripperger 1948). In this article, the author explained the advantages of rooming-in and criticized current hospital practices that emphasized "routines" and made mothers and babies live by the hospital clock. The author claimed that "the hospital takes over and you conform" and encouraged readers to ask for rooming-in because "the baby belongs to you and not to the hospital."

Some physicians began to speak out for more humane ways to birth babies. Grantly Dick-Read, a British obstetrician, made a significant contribution to humanizing childbirth with his book, Childbirth Without Fear (1944). In this publication, he presented his theory on the "fear-tension-pain syndrome," which explained that the discomforts of labor could be worsened by the effects of fear and tension. Women began preparing themselves for birth using Dick-Read's methods and found that their pain was relieved and birth was a rewarding experience again.

The 1950s

By 1952, only 4.5 percent of all births in America were attended at home by midwives (American Journal of Public Health 1983). Most births were now occurring in hospitals with the focus on childbirth as an illness in a medical-dominated culture (Wertz and Wertz 1989).

While many women had acceptable birth experiences, many others bitterly reported to magazines about "cruelty in maternity wards." In May 1958, the Ladies' Home Journal published letters from American women in an article titled "Journal Mothers Report on Cruelty in Maternity Wards" (Shultz 1958). Women reported being strapped down on delivery tables or being left alone for long periods of time while in labor. One woman wrote: "Our biggest enemy is smugness and indifference."

In the early 1950s, Dr. Dick-Read toured the United States speaking about his theory on the cause of pain in childbirth and described relaxation and breathing methods that deal with the pain. Women eagerly listened and found in his work the promises they had been seeking.

In 1953, British psychiatrist John Bowlby spawned the attachment theory when he claimed in his widely read book, Child Care and the Growth of Love, that children suffer catastrophically when they experience "maternal deprivation." Attachment-the lifelong love relationship between parent and child-reflects millions of years of evolutionary history. The mother buffers her child from the big scary world. How she does this can profoundly impact the child's ability to function socially as well as the child's basic biology. When informed about the importance of close contact with their babies in order to foster attachment, more and more women requested the rooming-in experience.

Seven suburban women eager to promote the "womanly art of breastfeeding" founded the La Leche League in 1956. At the time, only about 20 percent of American women breastfed their babies, but many were learning about the benefits of breastfeeding and were eager to try it. These women welcomed breastfeeding assistance from the La Leche League (Leavitt 1989).

In 1959, Marjorie Karmel's book, Thank You, Dr. Lamaze!, extolled the "natural" childbirth method and suggested breathing and nonpharmacologic techniques that women could use to cope with the pain of labor. At the same time, pioneering midwives and nurses were working to humanize birth in hospitals. They approached conventional hospital birth from a nursing perspective and proposed new ways to practice. Ernestine Wiedenbach, a certified nurse-midwife, published a text titled Family-Centered Maternity Nursing in 1959. In her book, she challenged conventional nursing practices by encouraging nurses to provide supportive nursing care based on recognizing and understanding the needs of each mother, father, infant, and family (Wiedenbach 1959).

Hennel, a nurse manager, wrote of family-centered maternity nursing and its philosophy of keeping the family together as a unit as much as possible. She and her staff had already implemented a family-centered maternity care philosophy in a hospital maternity program in 1956 (Hennel 1968). Hennel began the process by hand-picking all her staff, even the housekeepers, according to their belief in family-centered care and willingness to practice in a family-centered manner (Kuhn 1984).

It was becoming increasingly clear to a small group of professionals and to many women that families had relinquished a great deal of power with the transition of birth from home to hospital in the hope that healthier outcomes would prevail. The medicalization of childbirth was so successful that consumers and professionals in the forties and fifties who suggested there could be a better way to birth were seen as revolutionary.

The 1960s

In the 1960s, the FCMC social movement gained momentum when consumer organizations formed and advocated for family-centered maternity care. The first of such groups to organize was the International Childbirth Education Association (ICEA), founded in 1960. Since its inception, the ICEA has subscribed to the motto "Freedom of choice based on knowledge of alternatives."

When serving as ICEA copresidents, Doris and John Haire authored a manual titled Implementing Family-Centered Maternity Care with a Central Nursery (1968) in which they proposed family-centered maternity care to strengthen the new family unit. They had encountered difficulties in finding an environment in which they could share a meaningful childbirth experience, and this sparked their interest in family-centered care.

In New York in 1960, Elisabeth Bing and Marjorie Karmel formed the American Society for Psychoprophylaxis in Obstetrics (ASPO). This national organization promoted the Lamaze method and prepared Lamaze teachers (Phillips 1996).

The National Association of Parents and Professionals for Safe Alternatives in Childbirth (NAPSAC) was also influential during this time. This association, led by David Stewart, executive director, held seminars and published and lobbied for safe alternatives to conventional obstetrical practices. NAPSAC emphasized a strong commitment to family values and responsibility in childbearing.

Dr. Robert Bradley, a Denver obstetrician, published Husband-Coached Childbirth in 1965. In his book, Dr. Bradley proposed and advocated a true natural childbirth, without any form of anesthesia or analgesia using breathing and relaxation techniques for labor and birth supported by a "husband coach" (Bradley 1981). The American Academy of Husband-Coached Childbirth (AAHCC) followed Dr. Bradley's work, promoting his methods and training teachers.

These organizations prepared numerous childbirth educators in communities throughout North America. Teaching in their homes, in churches and schools, and occasionally in hospitals, these educators advocated for maternity care that would respond to the physical, emotional, and psychosocial needs of the mother, the baby, and the family. Childbirth educators discussed the pros and cons of perineal shaving and enemas in early labor and physiologic positioning and analgesia usage during labor. They questioned the need for episiotomies. Women and their partners were taught relaxation and breathing techniques to cope with the pain of labor. The value of breastfeeding and a support person's presence during labor were discussed. As childbearing couples became better informed, they asked more questions of physicians and nurses, and the most frequently used word was "Why?" If the answer was "hospital policy," families challenged that answer with another "Why?" until they received a satisfactory response.

Electronic Fetal Monitoring

Obstetrics is a competitive buyers' market because pregnancy is a normal biological process that occurs over nine months, allowing women to shop for their caregiver and place to birth. Professional groups and the families they taught created consumer pressure that had a great impact on prevailing hospital routines and obstetrical practices. Some hospital practices did change, particularly in liberalizing certain rigid routines. However, a new routine-electronic fetal monitoring (EFM)-was introduced in the late 1960s (Haggerty 1999). Women whose prenatal classes had taught them about physiologic positioning for labor were now required to lie flat in bed to avoid disturbing the fetal monitor tracings. Enamored with the new technology, hospitals quickly used it for nearly all pregnant women.

The 1970s

The 1970s were a turbulent decade that brought an end to many traditional values and beliefs. More consumers began researching physicians and places to birth, inquiring about hospital regulations, and requesting rooming-in and the fathers' presence in the delivery room. Although some hospitals had liberalized their policies and procedures to "allow" husbands to be present for labor and birth, others were still holding to rigid, restrictive, exclusive policies and procedures.

Educated, middle- and upper-income childbearing couples became more and more impatient. Concerns about overused hospital technology (especially electronic fetal monitoring), lack of family involvement, and loss of personal control led them to seek home birth as an answer (Pearse 1987). Physicians attended some home births, certified nurse-midwives attended more, and lay midwives attended many.

Alternative Birth Centers

Hospitals and physicians responded to families' desires for a less institutional experience by opening alternative birth centers (ABCs), also called "birthing rooms." ABCs offered homelike environments in hospitals, usually on the maternity unit. Husbands and children could be present in the birthing room. Families could be admitted to the birthing room, labor and give birth there, and have the baby remain with the family until discharge from the hospital. They did not have to experience the multitransfer, surgical-style obstetrical service.

Families interested in this alternative to conventional hospital birth had to meet hospital criteria, which usually included attending childbirth preparation classes, desiring nonmedicated labor and birth, family participation, a willingness to provide complete care for their baby, and being designated medically low risk. Since obstetric interventions (other than episiotomy) were typically not permitted, deviations from normal labor resulted in immediately transferring the woman to a conventional maternity unit. Partly because of these restrictions, few physicians encouraged their patients to use the ABCs.

Some hospitals had only a limited number of nurses willing or able to provide nursing care in the birthing room setting; therefore, staff availability could determine birthing room usage. Also, many women were "risked out" of the birthing room when they needed intravenous fluids or electronic fetal monitoring for fetal indications. In spite of these barriers, many women who would have chosen home birth instead came to hospitals because of the birthing room option (Tegtmeier and Elsea 1984).

Freestanding Birthing Centers

Led by the Maternity Center Association (MCA) in New York City, "freestanding birth centers" soon emerged (Pearse 1987). These centers offered essentially low-risk childbearing women and their families a low-intervention style of maternity care.

Support for FCMC

Then in 1978, a consortium of professional organizations including those representing obstetricians, pediatricians, nurses, and certified nurse-midwives published a document entitled Family-Centered Maternity/Newborn Care in Hospitals. The booklet called on all hospitals to change attitudes and practices related to the care of pregnant women and their families and spelled out specific ways to accomplish these changes (Pearse 1987).

In the fall of 1979, the Cybele Society was founded to research and promote family-centered maternity care. This organization was established as a forum for a wide range of maternity care providers, including obstetricians, pediatricians, nurses, midwives, anesthesiologists, family practitioners, and hospital administrators.

Thirty years after Dr. Jackson's rooming-in project and Dr. Grantly Dick-Read's first book and almost twenty years since ICEA was formed, hospital programs now offered prepared childbirth classes.

The first wave of the family-centered maternity care social movement was over. A hard-fought battle had been won. Advances included allowing fathers to be present in delivery rooms and liberalizing visitation. But most women were still separated from their babies after birth and were moved through the assembly line of labor to delivery to recovery and then to postpartum. Electronic fetal monitoring was accepted into widespread use and the cesarean birth rate increased from 5.5 per 100 births in 1970 to 14.7 percent in 1978 (Taffel et al. 1987). Questions began to arise about the association between widespread use of electronic fetal monitoring and the rising cesarean birth rate.

The 1980s

As competition for the childbearing population increased in the 1980s, most hospitals altered the physical and facility design of their maternity units. Many hospitals consolidated the old multitransfer surgical design of separate labor, delivery, recovery, and postpartum units into multitransfer labor-delivery-recovery (LDR) rooms and postpartum units with separate well-baby nurseries. Some hospitals changed their physical facility to one room for labor-delivery-postpartum and well-newborn care (LDRP rooms) and did not build central nurseries. Instead, these hospitals designed small "baby holding or respite areas" where babies could be watched when away from their mothers' rooms for short periods of time.

Hospitals that did not build central nurseries designed their nursing practices to facilitate nonseparation of mothers and babies. In so doing, postpartum and nursery nurses were cross-trained to function as mother-baby or couplet nurses.

The Situation Today

In the last months of the twentieth century, family-centered maternity care has become almost a cliché. For a hospital to admit that family-centered maternity care is not a priority is to commit economic suicide. However, the programs of care offered in many of the new facility designs of LDR and LDRP rooms actually maintain a persistent philosophical orientation to high-tech care in labor and an aggressive labor and birth management style (Midmer 1992). Relatively few hospitals actually practice true family-centered maternity care. On the brink of a new century, we have come a long way in humanizing American maternity care in hospitals, but we still have a long way to go. Changing to family-centered practice forces physicians and nurses to redefine their roles and develop relationships with families that are based on mutual respect and trust. In family-centered care, birth is considered to be a healthy event, unique for each individual. Women have autonomy in decision making, and professionals assist but do not direct women and their families.

Many physicians and nurses are torn between their belief in family-centered care and their desire to hold on to the old clinical practice ways into which they were socialized. Changing to family-centered care requires a change in attitude, and this must start at the top of the organization with its administration. It is essential that the chief of obstetrics and the nurse leader believe in the importance of family-centered care and role model the necessary behaviors. Every staff member who comes in contact with a childbearing woman and her family must understand and practice family-centered care.

Family-centered maternity care began as a social movement to empower childbearing women and their families to have responsibility and control over a basic life event: the birth of a family. At the very core of a family-centered maternity program is the belief that childbirth is the beginning of a family: the basic unit of society. The birth of a baby instigates major role transitions. Perhaps the most important of these is the transition to parenting. There is no turning back. Parenthood is the most important role a human being can take on in life. Parents are on the front line in the battle to determine their children's mental health. Relationships in early childhood have a tremendous impact on later development and health. It is critical that health care professionals who interact with childbearing families foster the parenting role. Family-centered maternity care gives priority to family formation.

As the twenty-first century begins, it is time for the next phase of the social movement that is "family-centered maternity care." Childbirth educators are really family educators. It is not enough to teach pregnant couples about their care and the circumstances surrounding labor and birth. Women and their families need information on the importance of nonseparation of the new mother and baby, the inclusion of family members in getting to know the new baby, and the importance of healthy parenting and healthy families. Women need to know that pregnancy and birth are normal, wholesome events that belong to them. Empowering women was never about pretty rooms for birth or about giving away the birth experience to technology or anesthesiologists or nurseries. Empowering women has always been about education and support so they can confidently birth their babies and become competent mothers.

The challenge for childbirth educators in the twenty-first century is threefold. We must:

• Help men and women understand that birth itself has the potential to change lives for the better.

• Give women a sense of fulfillment and tremendous accomplishment.

• Give new parents a strong connection to the very essence of life.

When these challenges are met, we will finally experience true "family-centered maternity care."

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"Family-Centered Maternity Care: Past, Present and Future" by Celeste Phillips, published in the 1999 International Journal of Childbirth Education, Volume 14, Number 4, has been reprinted with the permission of the International Childbirth Education Association, Minneapolis, Minnesota USA. This does not include the rights to resell the reprint.