Family-Centred Maternity and Newborn Care: National Guidelines

A Paper Describing the History, Process of Development, and Overview of the Content of the 4th Edition.

Prepared for
Division of Childhood and Adolescence

by

Louise Hanvey

Introduction

In 2000, Health Canada published the 4th Edition of the national guidelines for maternal and newborn care in Canada Family - Centred Maternity and Newborn Care: National Guidelines . This article describes the history of these Guidelines , the process undertaken for the production of this 4th Edition, and highlights the contents of the Guidelines .

The Definition of Family-Centred Maternity And Newborn Care

Family-centred maternity and newborn care is a complex, multidimensional, dynamic process of providing safe, skilled and individualized care. It responds to the physical, emotional and psychosocial needs of the woman and her family. In family-centred maternity and newborn care, pregnancy and birth are considered normal, healthy life events. As well, family-centred maternity and newborn care recognizes the significance of family support, participation, and choice. In effect, it reflects an attitude rather than a protocol.

The History of these Guidelines

Guidelines for maternal and newborn services were first published in Canada by the department of National Health and Welfare in 1968 and subsequently revised in 1974 and again in 1987. Changes were made in each version in keeping with the rapid changes which had occurred in maternal and newborn care in Canada. The first two versions of the Guidelines were titled Recommended Standards for Maternity and Newborn Care. In 1975, when the first revision took place, family-centred maternity and newborn care was not yet widely accepted as essential for mothers, babies and families. By 1987, the principles of family-centred maternity and newborn care and the importance of its implementation was more widely recognized. Therefore the title of the Guidelines was changed to Family-Centred Maternity and Newborn Care: National Guidelines .

The Current Context for Maternal and Newborn Care

In the mid-nineties it became apparent to government, professional and voluntary groups that the 1987 Guidelines needed revising. However, the state of the world of maternal and newborn care and the environment in which that care was being offered was changing rapidly and dramatically. Over the previous 30 years, a number of fundamental changes had influenced the provision of maternal and newborn care in Canada.

Technology

It is no secret that an explosion in technology has occurred. New and more sophisticated technological tools have become available for maternal and newborn care; for example, electronic fetal surveillance and invasive pain-relief measures. Clearly, information technology has changed the health care system.

Consumer and Professional Participation

Today, a consumer and professional movement is in place, predicated on the belief that birth is a natural, family event that suffers if an "illness model" is applied to the care of families during the childbearing cycle. The routine application of technology, as well as many other routine practices, in maternal and newborn care, are being questioned. Many are insisting that women and families be full participants in decisions regarding their care.

Health Care Restructuring

A restructuring of the health care system is ongoing, with consequent fiscal constraints. Although this restructuring has varied by region across Canada, some similarities have surfaced. For example, a move has occurred to decentralize services from the provincial level to municipalities, with regionalization emerging in some areas. Institutions are downsizing or closing, and transferring services. Hospital stays are becoming shorter.

Evidence-based Practice

Increasingly, health care practices are being questioned and evidence-based practices demanded. In effect, maternal and newborn care has played a central role in the development of this evidence-based practice. The Oxford Database of Perinatal Trials (now the Cochrane Collaboration Pregnancy and Childbirth Database) was the first comprehensive resource to provide systematic, evidence-based reviews concerning the efficacy of interventions. Clinical practice guidelines, based on the evidence, have now proliferated in the fields of medicine, nursing and midwifery.

Diversity of the Canadian Population

The Canadian childbearing population has become even more diverse in terms of culture, ethnicity, race, socio-economic status and age. The social supports and resource systems that are available for families and communities vary widely. Today, more women of childbearing age are employed outside the home. More women are delaying childbearing until an older age. Yet, many families are isolated from the support of extended families. Programs and services therefore need to be responsive and accessible to these diverse needs. It is important, too, that all services recognize the special characteristics of the community they are designed to serve. They should be attractive and accessible to women and their families, particularly those who may be least inclined, even reluctant, to use them. This diversity poses a challenge to all involved in maternal and newborn care.

The Process for Developing These Guidelines

In order to address the complexity of the current environment within which these Guidelines would have to be utilized, it was recognized that the Guidelines would have to be written in a collaborative fashion, involving all potential stakeholders. Therefore, a three phase, participatory process was developed to develop and produce the Guidelines .

Phase One

To begin with, in order to confirm that the Guidelines were still needed and to explore what should change from the 1987 Edition, a User Feedback Survey was conducted. Questionnaires were distributed to 100 potential users of the Guidelines - professionals working in maternal and newborn care in a variety of settings (hospitals, community agencies, governments and educational settings). The survey asked questions in the following general areas:

• What would make the Guidelines more useful?
• As general topics, are the chapters in the 1987 Guidelines still relevant? What is missing?
• What could be deleted?
• Is the format of the Guidelines useful? Are they easy to follow?

Based on 66 responses, the Survey revealed the following.

• The vast majority of the respondents had seen the Guidelines and three-quarters of them had used them.
• All but one respondent supported the continuation of the Guidelines and saw them as a useful tool in the field.
• All respondents identified that a major re-write of the content of the Guidelines was necessary.
• The majority of respondents recommended that the Chapter headings of the 1987 were still relevant.
• Respondents identified that what would make the Guidelines more useful was marketing and implementation emphasizing that the Guidelines should be marketed widely to administrators, practitioners, to the general public and to heads of departments.
• Respondents felt that the overall philosophy and tone of the 1987 Guidelines did not adequately reflect the principles of family-centred care as they are currently understood, and that this needed to be addressed.
• Respondents were emphatic that the Guidelines be based on research and evidence, and that this be a strong theme for the new book.
• Respondents felt the Guidelines should build on currently available national clinical practice (and other ) guidelines and that they not "re-invent the wheel".
• Particular content that respondents wanted to see addressed in the new Guidelines (that was not in the old) was consumer participation, choice, the place of technology, breastfeeding, community-based care, and the inclusion of all personnel (e.g., midwives, doulas).
• The vast majority of the respondents found the size, format and layout of the Guidelines useful and satisfactory. The recommended changes were to include references after each chapter, to use figures and boxes, and to make the Guidelines available in an electronic format.

Based on this feedback the decision was made to proceed with the revision of the Guidelines . Since there are so many stakeholders involved in the care of mothers and babies in Canada, the revision process needed to be participatory and inclusive, in order to increase the likelihood that the Guidelines would be used and have an impact. In order to address this, a Core Group of national professional and consumer organizations was established. The membership of this group is seen in Figure 1. The Core Group met twice to plan the process for revising the Guidelines . They identified recent information that was relevant to the development of the Guidelines ; they planned the process for writing the Guidelines ; they made recommendations regarding the structure of the Guidelines ; they identified participants for working groups to write the Guidelines ; and they planned for the roles of their participant organizations in the dissemination and implementation of the Guidelines .

Phase Two

Based on recommendations of the members of the Core Group, individual Working Groups were established to write the content of the Guidelines . These Working Groups were staffed by a Project Director. There were 13 working groups, organized around the content of the Guidelines :

1. Introduction and Philosophy
2. Organization of Services
3. Preconception Care
4. Care During Pregnancy
5. Care During Labour and Birth
6. Combined Care of the Mother and Newborn (four groups)
7. Breastfeeding
8. Loss and Grief
9. Transport
10. Facilities and Equipment

Each of these Working Groups was interdisciplinary in nature. The disciplines were medicine (neonatology, obstetrics/perinatology, anaesthesia, and family medicine); nursing (community and hospital); midwifery; families; childbirth education; administration; architecture and planning. The members of the Working Groups were volunteers. They were chosen based on their expertise in particular subject areas. They represented all regions of the country. These volunteers met by conference call to establish the outline for their chapter, discuss the specific content and review drafts. They continued their work through E-mail, fax and mail communication. The volunteers each wrote specific areas of the content and the Project Director drew the content together and edited/revised the chapters. Each of the chapters went through three or four drafts during this process.

Phase Three

Phase three of the process encompassed a two-part review process. Specific chapters and/or the entire document were reviewed by some Working Group members and other volunteer reviewers. In addition, the entire document was reviewed, revised and finalized by a formal Editorial Review Team. This Team of 15 individuals, was interdisciplinary in composition, represented each of the Working Groups, and had outside representatives who had not previously been part of the process. Each member had expertise in the related content. The Editorial Review Team reviewed and provided feedback on three further drafts of the Guidelines . They identified, discussed and came to resolution on contentious issues. The Team worked exclusively via teleconference each Chapter requiring at least three calls and the Project Director was responsible for revising and editing the Drafts according to the Team's recommendations.

The result of this tremendous volunteer effort was the newly revised Family-Centred Maternity and Newborn Care: National Guidelines - 1999.

The Purpose of the Current Family-Centred Maternity and Newborn: National Guidelines

The purpose of the Family-Centred Maternity and Newborn: National Guidelines is to assist hospitals and other health care agencies in planning, implementing and evaluating maternal and newborn programs and services. Although designed for policy makers, health care providers (e.g. physicians, nurses, midwives), parents, program planners and administrators, these are not clinical practice guidelines. Current clinical practice guidelines, however, are referred to and abstracted throughout the document.

Because of the diversity of Canada's regions and communities, the Guidelines are intended to be sufficiently flexible to encompass the various approaches, policies and protocols of Canadian institutions, agencies, communities and regions.

The Content of the Guidelines

The Guidelines are organized from general principles to specific details. Chapter 1 begins with an introduction to the concepts of family-centred maternity and newborn care and a description of the basis of this care - the guiding principles. Chapter 2 describes the organization of services within a regionalized system of family-centred maternity and newborn care. The next four chapters provide guidelines for providing care during the childbearing cycle: preconception care, care during pregnancy, care during labour and birth and early postpartum care of the mother and infant and transition to the community. The next three chapters address specific topics of concern relative to family-centred maternity and newborn care: breastfeeding, loss and grief and transport. The final chapter describes the guidelines for the facilities and equipment necessary when providing care.

Each chapter begins with the particular guiding principles relevant to the aspect of maternity and newborn care under discussion. Each chapter also includes its own references to the literature. The appendices at the end of most chapters provide more detailed information in specific areas.

These Guidelines are based on research evidence. If the evidence is unclear or an area of care remains controversial, it is noted. If a clear benefit has emerged based on strong research evidence, it is detailed. Where there are risks, they are defined. Finally, if the research is nonexistent or limited, it is recommended that evidence be developed.

TheFamily-Centred Maternity and Newborn Care: National Guidelines are based on a number of guiding principles. These principles are found in Figure 2. They recognize that pregnancy and birth are unique experiences and for most women and families a normal, healthy process. Families are central to care as is informed choice. Relationships between women and care providers are based on trust and mutual respect, and it is recognized that health care providers can, and do, have a powerful effect on women and families who give birth. Technology is used appropriately and all care is based on research evidence however it is recognized that there are a number of indicators of quality that need to be examined in this research.

Conclusion

The Family-Centred Maternity and Newborn Care: National Guidelines , 4th Edition, were developed as a result of a collaborative process involving health care providers and consumers. As we move into the next millennium, these Guidelines will help us achieve the objective that we all share - a healthy and satisfying pregnancy, birth and postpartum experience for all mothers, babies and families.

Figure 1 Core Group Members

• Aboriginal Nurses Association
• Association of Women's Health, Obstetric and Neonatal Nurses - Canada
• Canada Anaesthetists' Society
• Canadian Coalition for the Prevention of Developmental Disabilities
• Canadian Coalition for Regionalized Perinatal Care
• Canadian Confederation of Midwives
• Canadian Council on Health Services Accreditation
• Canadian Healthcare Association
• Canadian Institute of Child Health
• Canadian Medical Association
• Canadian Nurses Association
• Canadian Paediatric Society
• Canadian Public Health Association
• Canadian Women's Health Network
• College of Family Physicians of Canada
• Consumer representatives
• International Childbirth Education Association
• Native Physicians Association in Canada
• Society of Obstetricians and Gynaecologists of Canada

Figure 2 Guiding Principles

• Birth is a celebration - a normal, healthy process.
• Pregnancy and birth are unique for each woman.
• The central objective of care for women, babies and families is to maximize the probability of a healthy woman giving birth to a healthy baby.
• Family-centred maternity and newborn care is based on research evidence.
• Relationships between women, their families and health care providers are based on mutual respect and trust.
• Women are cared for within the context of their families.
• In order to make informed choices, women and their families need knowledge about their care .Through respect and informed choice, women are empowered to take responsibility.
• Health care providers have a powerful effect on women and families who are giving birth.
• Family-centred care welcomes a variety of health care providers.
• Technology is used appropriately in family-centred maternity and newborn care.
• Quality of care includes a number of indicators.
• Language is important.