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BIRTH 19:4 December 1992

EDITORIAL

Family-Centered Maternity Care: Is the Central Nursery Obsolete? Flexibility has always been stressed as an essential ingredient of family-centered maternity care-the ability to change and adapt to the needs of mothers, babies, and families, and respond to new research as it comes along. Over the past 25 years we have seen welcome changes in clinical practice to support families and increase choices in many hospitals, with mother-baby nursing, sibling visiting, more opportunities for parent-infant bonding, midwifery care, parent involvement in neonatal intensive care units, and partners sharing in cesarean births. We see more women walking around in labor, and fewer perineal shaves, enemas, and episiotomies. Changes have been made in the physical environment, such as adjustable birthing chairs and beds, labor-delivery-recovery (LDR) and labordelivery -reco very - po s t par t um (LDRP) rooms (birthing rooms), labor lounges, and showers and Jacuzzis. Other logical changes have not evolved; one of these is the closure of central nurseries. Before starting in any bold new directions, however, it might help to keep some points in mind. First, hospitals have to keep the flow of fresh ideas and energetic action alive and well so that care policies and practices do not become set in stone. When Sister Mary Stella first introduced the concept of family-centered maternity care over 30 years ago in Evanston, Indiana, she understood this principle well when she wrote, “It would be presumptuous to leave the reader with the thought that our [family-centered maternity] program is in itself a finished product . . . but rather it must and shall undergo continual change . . . made solely in terms of the needs of all concerned as we come to a better understanding of those needs” (1). Second, hospitals must think and practice accountability so that changes come from real understanding of whose needs should be paramount, who is accountable to whom. As many critics have noted, changes often are more cosmetic than real. Hospitals pick the elements that they want, rather than listening and responding to what the patients and community want.

Third, hospitals have to respond to research findings that demonstrate whether or not specific forms of care are effective, abandoning those that experts agree “should be abandoned in the light of the available evidence” (2). Such care practices include, for example, separating healthy mothers and babies, and scheduling the timing and duration of breastfeeds routinely (2). If we consider these points with the central nursery in mind, it may be hard to justify its continuation on the basis of need. We take for granted the health focus, familyoriented care, and absence of a nursery in the freestanding birth center, but injecting these elements into the sickness-oriented hospital is a difficult undertaking. In addition, birth centers usually have a permanent consumer advisory board of mothers and parents that shapes policies and monitors response to the needs of the centers’ families. It is the rare hospital consumer advisory group that is invited to help achieve the sweeping changes required to move a hospital toward the birth center philosophy and level of low-risk care. One hospital I visited recently is on its way to doing just that. Wellesley Hospital in downtown Toronto is a teaching hospital of the University of Toronto that serves a multiethnic population. As the chief of obstetrics unrolled the architect’s plans on his desk, I did not expect to be surprised by what I saw and heard, but I was. Dr. Paul McCleary has been enthusiastically committed to family-centered maternity care for several years. He has organized seminars, studied, listened, and moved from one hospital to another to pursue his goal of establishing a family-centered unit that will be “a community hospital providing low-risk care in an academic environment.” The model he follows is his own, guided by the community advisory panel he established at the beginning, and with the support of the Ontario Ministry of Health and his hospital administration. The panel, made up of parents, consumers, and community caregivers, helped to choose the architects and plans. “This is their concept, their plan; they were given free rein,” Dr. McCleary told me.

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When the unit opens early in 1994, midwives will be on staff, having achieved legal status by that time (3). From 1600 births a year now, it expects to build to 2400 births, which will take place in an environment very different from the traditional maternity unit. Each mother and baby will spend their entire stay in one of 18 LDRP rooms, arranged in three “pods” of six rooms. Instead of a normal newborn central nursery, each pod will have a large central kitchen-dining room that will be the hub of communications for staff, patients, and families, “so perhaps they will begin to talk to each other.” The unit will also have a conference and staff room, one operating room for cesarean sections, and a small observation nursery of four or five beds for needy babies. Over 40 years ago Dr. Angus McBryde wrote, “It is hoped that hospitals in the future will be built without nurseries for normal newborn infants who are born of healthy mothers” (4). Ten years ago Drs. Marshall Klaus and John Kennell echoed those hopes, saying, “We believe that in the near future, placement in the large central nursery will be phased out for most babies” (5). But these suggestions have not been welcomed by most physicians. Although eliminating the central nursery is also integral to the single-room maternity system, few hospitals have done so. Also missing in the Wellesley Hospital plans is the nursing station: “The nurses and midwives will be taking care of the mothers and babies in their rooms,” said Dr. McCleary. Continuity of care will be ensured, with the same team of nurses and midwives looking after each motherbaby pair throughout their stay. This new physical environment has been specifically designed to match the plans for caring for healthy mothers and babies. State licensing regulations in the United States have long stood in the way of such a major departure from tradition, requiring hospitals to have normal newborn nurseries, even though they usually stand empty where mother-baby nursing is practiced, thus wasting valuable space and money. In other hospitals, less committed to real familycentered care, nurseries continue to be filled with babies who would be better off with their mothers so they could get to know each other during their

BIRTH 19:4 December 1992

brief (and becoming briefer) hospital stay. After all, we know that if the nursery is there it will be used. We also know that no research has proved that restricting a mother’s access to her baby is safe or beneficial and should be continued (2). Such restriction, however, is precisely what the central nursery achieves. Good news about doing away with these nurseries also recently came from Pasadena, California, where Dr. David Wirtschafter, Regional Coordinator of Perinatal Services for Kaiser Permanente Medical Care Program, southern California region, announced that building plans for new hospitals in the future will have no large central nursery. A small eight-bed nursery is planned for the first hospital with the new design, and it will open in 1994 anticipating 4000 births per year. Obtaining provisional agreement from the county health department took I1 persuasive pages worth of effort, he told me, but, “We don’t want to separate the mother and baby, and we expect them to be together during their short stay.” Thus, not only will the parent-newborn relationship get off to a good start, but hospital space, dollars, and staff resources will be saved. The winds of change from Toronto and Pasadena bring refreshing new meaning to family-centered care. If other hospitals follow their lead and keep good research data on the effectiveness of providing hospital maternity care without a central nursery, perhaps health regulatory agencies everywhere will finally adopt the new design, and mothers and babies will benefit. Diony Young References 1 . Stella M. Family-centered maternity care: How it works. Hosp Progr 1960;41:92-94;70-72, 158. 2. Chalmers I, Enkin M, Keirse MJNC, eds. Effective Cure in Pregnancy and Childbirth, vol 2 . Oxford: Oxford University Press, 1989:1477. 3. Kaufman KJ. The introduction of midwifery in Ontario, Canada. Birth 1991 ;18(2):100-103. 4. McBryde A. Compulsory rooming-in and private newborn service at Duke Hospital. JAMA 1951;145:625428. 5 . Klaus MH, Kennell JH. Parent-lnfant Banding. St. Louis: CV Mosby, 1982.

Family-centered maternity care: is the central nursery obsolete?

183 BIRTH 19:4 December 1992 EDITORIAL Family-Centered Maternity Care: Is the Central Nursery Obsolete? Flexibility has always been stressed as an...
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