The Regional Office for Europe and the Regional Office for the Americas of the World Health Organization held a joint Symposium attended by over 40 Participants from North and South America and Europe, representing obstetricians, paediatricians, health administrators, sociologists, psychologists, economists, epidemiologists, medical journalists and service users.
Certain rights are fundamental to attitudes and approaches in care following birth. For example, the right to
3. The structure of health care systems and the way they operate are influenced by commercial interests and by the needs and perspectives of professionals and others who work in them. When such influences are strong, they need to be publicly recognized and, if necessary, controlled.
4. The improvement of care following birth must be a collaboration between:
5. All countries need a systematic process of health planning, including resource allocation for the care of women and babies. This process would ideally be both local and national, and it would reflect the views of a broad cross- section of professionals and interested groups in the community. Planning for the health of women and babies must go beyond an approach based on potential risks to the physical health of the woman, fetus and newborn infant; a positive effort is called for to involve the entire society in the promotion of health.
6. The allocation of health care resources to intensive life support systems for the newborn should be determined nationally. That decision must be informed by research findings, socioeconomic factors, and moral and ethical considerations. It should be based on consultations among care providers and representatives of parents and the community as a whole. It should include the establishment of minimum standards and requirements for staffing, equipment, and the siting of units for the newborn.
7. Mothers are the primary and continuing human resource available to sustain optimum infant development. They must be given general and specific partical support so that they can carry out this primary role.
8. Every woman in employment should have an adequate period of paid maternity leave before and after childbirth. Social security systems should not penalize women for motherhood. Women should also be relieved of unpaid work after childbirth, and home help services should be available. After birth, paid leave should be provided for the father so that he can foster a relationship with the baby and support the mother.
9. Self-help groups should be promoted and funded in local communities to enable parents to meet the responsibilities of infant care. Professionals have a duty to be knowledgeable about self-help groups in the community and they should inform parents about these groups. As one example, breastfeeding support groups in the community provide a valuable form of information exchange and support among women.
10. In any country or region existing cultural practices in the period following birth should be respected and maintained - unless they have been proven harmful. Better communicating between women and health workers would improve opportunities to recognize strengths of local traditions, which could then be disseminated to other women.
12. If the mother desires breastfeeding, it should be initiated within the first hour after birth. Practices concerning breastfeeding should follow the resolutions adopted at the Thirty-fourth World Health Assembly in 1981.
13. All parents and newborn infants have the right to be in close contact from the time of birth. Closeness between mother and infant should be promoted in all circumstances, including the period after Caesarean birth or other medical interventions affecting the woman or infant. Women and babies should not be separated and should be together as much as the mother wishes. Rooming-in should be promoted; and thought should be given to abandoning central nurseries for normal babies. Furthermore, involvement of parents in the care of the unhealthy newborn should be promoted, including the actual care of the unhealthy infant and participation in decisions about treatment.
14. Mothers and babies should not be kept in hospital beyond the time when they can benefit from further hospital diagnostic or therapeutic measures. If rest or social or educational support are needed, they should be provided in the home.
15. Health care personnel should support efficacious and safe technologies, but they should not impose them on women and families. When the desire of parents is judged to go against the good of the infant, then a formal advisory system for solving these problems must be implemented in each health care facility.
16. Iatrogenesis (harm to the woman or her infant by diagnostic or therapeutic measures) should be avoided, for example harm from treatment of jaundice in the newborn. Jaundice affects many full-term newborn infants, but the vast majority of them are healthy and do not need diagnostic investigations or treatment.
17. Since hospital-acquired infections are a major threat to women and infants, hospitals should monitor their infection rates and introduce programmes for the prevention of such infections. Rooming-in rather than a central nursery can be an important part of such a programme. Early discharge of women and infants would also be part of such programmes.
18. Every baby should have its own record from the moment of birth, which may include data about pregnancy and birth. This record, or at least a copy of it, should be kept at home by the woman. It would include data about growth, development, nutrition, immunization and medical history. It can form a basis for communication among givers of health care and with the woman. The woman should also have her own health record in her home. Confidentiality of these records must be protected.
19. Resources should be allocated, both in hospital and in the community, to the follow-up of the health of the newborn infant and the woman. Ideally, personnel involved in the birth and in hospital aftercare would make the first home contact with the woman and family to enquire about their wellbeing. Every woman and baby should have the opportunity to receive community-based health care. Home-based care givers should encourage the promotion of health in the woman and her baby.
20. Home-based alternative technologies for women and babies, such as portable phototherapy for neonatal jaundice, should be developed to allow expansion of coverage to the population that lacks access to hospital care. Such innovations should be evaluated just as rigorously as complex hospital technology.
22. The period following birth may be an important time for making family planning advice and services available to both parents. The person giving such information to women should be someone in whom they have confidence. In many contexts, the best person will be a nurse or midwife. Information should be given on a variety of contraceptive techniques, so that women can make informed choices.
23. The eradication of neonatal tetanus is a high priority.
24. Low birth weight, which correlates strongly with both perinatal mortality and morbidity, should receive high priority for research into causes and prevention. Meanwhile, however, some actions seem to reduce the incidence of low birth weight and other causes of perinatal mortality and morbidity. Services should be developed with such actions in mind and the public should be fully informed of the reasons for an importance of these actions, which include:
26. Government agencies should support the provisions of health care by alternative providers, such as empirical midwives. The role and efficacy of these alternative providers should be systematically evaluated.
27. Every woman should receive basic care immediately following birth. In those parts of the world where haemorrhage, infection and pregnancy-induced hypertension are important causes of maternal mortality and morbidity, every effort should be made to provide effective treatment and to prevent long-term sequelae. An effective referral system is necessary for the woman when complications arise during pregnancy, birth, or the period following birth. Such a system must include free transport where necessary.
28. A first priority is that every newborn baby, whether born at home or in hospital, should be assessed for breathing difficulties and be given the necessary support to initiate and sustain respiration. Every birth attendant should be trained in and equipped to deal with immediate care and resuscitation of the newborn, including identification of the need for consultation or referral to more specialized care.
29. Every newborn baby should be evaluated initially for vital signs and gross congenital abnormalities. Evaluations should take place next to the mother if possible, in a room at the right temperature and without hazard to baby or woman.
30. Discharge from hospital should depend on the wellbeing of the mother and infant, the wishes of parents, and the availability of home support. In particular, discharge policies should not be based on the single criterion of weight and should concentrate on earliest possible discharge.
32. Parents have the right to early active involvement in the care of their unhealthy infant:
34. A woman who becomes seriously ill during pregnancy or labour or whose fetus is endangered should be provided with an appropriate level of care, ideally before birth. Transport must also be available for every unhealthy infant who needs care elsewhere. Vehicles for the transport of infants should be equipped with the basic means of maintaining body temperature and supporting respiration. If she wishes, the woman should be able to accompany her infant. A referral network must be established and understood by all concerned. The infant should be accompanied by the record prepared by the primary care provider. Communication between the different levels of care is important.
35. All countries should develop criteria by which to determine whether or not certain treatments for the newborn should be regarded as experimental. Examples of "experimental" treatment, in present circumstances, include the management of extremely premature infants and serious congenital defects. Guidelines should be formulated for the selection of infants for whom maximum intensive care and surgery are justified. The possibility of short- and long-term negative consequences of such treatment should be fully communicated to the parents.
36. Ideally, unhealthy infants requiring intensive care should receive it in special units within maternity hospitals. In these units, paediatric and specialized nursing staff should be on duty 24 hours a day. The minimum acceptable facilities for life support, including biochemical tests and radiology, should be available. No institution providing tertiary care should be permitted to refuse to accept a case presenting at their facility, at least for assessment, stabilization and referral.
38. Any technology used in care following birth should undergo evaluation before its introduction for general use. Such evaluation should include efficacy and safety, economic implications, and cultural acceptability. The results of technology assessment should be widely disseminated to professionals and the general public. WHO should continue to promote and expand a network of technology assessment centres to assist countries in selecting new technologies and assessing them. This network will constitute a focal point for the dissemination of information.
39. All research should use the strongest possible design. In the assessment of any technology, this design is a randomized controlled trial, probably a multi-centre collaborative trial that can achieve adequate sample size. Community-based research, organized by community groups and assisted by relevant experts, should be encouraged.
40. In improving care following birth research on the services themselves, including relevant social science research, can help to change both individual practices and policy. This type of research lacks funding and institutional support now enjoyed by biomedical research. Health workers should be encouraged to enquire into their own performance with the support of a competent team with expertise in study design, analysis of data, and dissemination of results.
41. Two areas of research needing high priority are:
43. All governments should appoint a broad-based representative committee, including health care providers and the users of health card, to establish guidelines and recommendations for the care of mothers and infants. These guidelines should be based on a continuing evaluation system and should be widely distributed and frequently revised. Such guidelines should include minimum standards for equipment and care practices following birth.
44. All countries should make an effort to improve perinatal records. Birth and death certificates should include birth weight, and they should be linked whenever possible. A good statistical system is essential, beginning with registration of all birth and deaths. Permanent perinatal surveillance systems are needed at the national level.
46. Those working in special care units face infants with severe illness, handicap, and often death, so they must be oriented to the implications of such stresses and how to cope with them, and they should receive emotional support. Regarding breastfeeding, special attention must be given to the training and practices of health professionals who come in contact with women in the postpartum period. Contradictory advice must be avoided. The practice of giving food other than milk during the first months is to be discouraged.
47. WHO should be active in ensuring that appropriate courses in public health, with special emphasis on maternal and child health, are taught at universities and schools of medicine, nursing and midwifery.
49. Information about the period following birth which is accurate, clear, attractively presented, of high quality and consistent should be disseminated widely to parents, schoolchildren, teachers, health professionals and politicians.
50. WHO and its regional offices should institute a regular programme of meetings with journalists, media and public relations leaders, and editors of professional journalists to familiarize them with the recommendations of WHO meetings and other issues affecting maternal and child health. WHO should promote the implementation of the recommendations of the Trieste meeting and the two earlier meetings.
WHO Regional Office for Europe (EURO)
Centre of Information on Public Health in the European Region (CIPHER)