In the spring of 2006, more then 50 grassroots activists attending the Coalition for Improving Maternity Services’ (CIMS) Conference in Boston, Massachusetts participated in a breakout session entitled “It Takes a Village.” Included in this group were birth activists from all across the United States and around the world. The activists met for a total of 6 hours over the course of the weekend and came out of their meetings with a new CIMS committee, the Grassroots Advocates Committee (GAC). Its intent was to develop a collaborative project to be called Transparency in Maternity Care.

Sandra Bitonti Stewart and Élan McAllister volunteered to co-lead the Grassroots Advocates Committee. A Steering Committee of five was quickly formed to help guide the Transparency in Maternity Care Project into fruition.


Co-Chair: Nasima Pfaffl, MA-Medical Sociology
Vice-President, Citizens for Midwifery; Board Member BirthNetwork National

Co-Chair: Elan Vital McAllister, BA – Gender and
Sexuality Studies
President and Co-Founder Choices in Childbirth; Board of Directors, Friends of the Birth Center
Co-founder, The New York Birth Coalition; Tony Award Winning* Broadway Producer (Cry Baby, Coram Boy, Spamalot, Hairspray, Metamorphoses, The Crucible, The Iceman Cometh)

Lisa Conforti, MPH, BA – Anthropology
Research Associate, American Board of Internal Medicine
Robin Elise Weiss , BA, CLC, ICCE-CPE,
Lamaze childbirth educator, doula, parenting author, doula and childbirth trainer; Author of The Complete Illustrated Guide to Pregnancy, The About.com Guide to Having a Baby , The Guarantee the Sex of Your Baby , The About.com Guide to Baby Care , The Everything New Mother’s First Year , The Joy of Pregnant Sex , The Everything Pregnancy Fitness Book and The Everything Getting Pregnant Book

Michelle Kendell, MBA, AAHCC, BS – Marketing Management
Co-Chair, CIMS; Birth Network National Board Member; Bradley Teacher

Ruth Wilf, CNM, PhD
CNM, Pennsylvania Hospital OB GYN and Midwifery Care

In the year that followed the 2006 CIMS conference, the Steering Committee members met twice monthly via conference call to flesh out the project. Using the discussions and ideas that came out of the “It Takes a Village” breakout session as the basis for their work, the Steering Committee Members created a project outline and developed the first drafts of The Birth Survey, a consumer survey that is at the heart of the project.

An outline of the Transparency in Maternity Care Project and a mock up of The Birth Survey were presented to the CIMS Leadership Team during their annual meeting in August of 2006. The outline and survey were met with enthusiasm, and the Steering Committee received the official green light to continue work on the project.

In the fall of 2006, many activists and experts in the field took the time to review The Birth Survey. We received insightful, thought provoking feedback that helped us take the survey to the next step in its development. We are so grateful for the input of so many from our community!

In the winter of 2006, market research was conducted to ensure that The Birth Survey addressed the needs of the public. Over 1,000 women responded to a brief, online, market research survey providing invaluable information about the issues that are most important to birthing women. The data collected from these responses have been reviewed and now act as a guide for further development of The Birth Survey.

In March of 2007, the Grassroots Advocates Committee, presented the Transparency in Maternity Care Project and The Birth Survey to attendees of the annual CIMS conference in Atlanta, Georgia. The presentation was met with a standing ovation and great interest and enthusiasm from all present.

In June 2007, The Birth Survey began its pilot project in New York City. In the Spring of 2008, the overall ratings for providers and facilities from the New York City Pilot were added to the website. CIMS Ambassadors began to be trained and sought to make facility-level intervention rates public. Heather Gardocki in Virgina was the first ambassador to get facility-level intervention rate data released to CIMS for Transparency in Maternity Care Project. Lamaze international awarded The Birth Survey the Lamaze President’s Award in the fall of 2008.

On August 15, 2008 The Birth Survey became nationally available to all women who gave birth in the US in the last three years. The CIMS Grassroots Advocates Committee continued to train project ambassadors and work to make facility-level intervention rates available.

On April 28, 2008 the national results for providers and facilities became available on the website. In April, the results for providers and facilities included overall ratings and recommendations. For providers, feedback on interpersonal and communication skills also became available. In the future women’s free-text comments will be added to the ratings. Eventually, the overall ratings will be expanded to include the in-depth information women provide through The Birth Survey. This data will be available as detailed custom reports.


The Coalition for Improving Maternity Services (CIMS) is a coalition of individuals and national organizations with concern for the care and well-being of mothers, babies, and families. Our mission is to promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs. This evidence-based mother-, baby-, and family-friendly model focuses on prevention and wellness as the alternatives to high-cost screening, diagnosis, and treatment programs.


In spite of spending far more money per capita on maternity and newborn care than any other country, the United States falls behind most industrialized countries in perinatal morbidity and mortality, and maternal mortality is four times greater for African-American women than for Euro-American women;
Midwives attend the vast majority of births in those industrialized countries with the best perinatal outcomes, yet in the United States , midwives are the principal attendants at only a small percentage of births;
Current maternity and newborn practices that contribute to high costs and inferior outcomes include the inappropriate application of technology and routine procedures that are not based on scientific evidence;
Increased dependence on technology has diminished confidence in women’s innate ability to give birth without intervention;
The integrity of the mother-child relationship, which begins in pregnancy, is compromised by the obstetrical treatment of mother and baby as if they were separate units with conflicting needs;
Although breastfeeding has been scientifically shown to provide optimum health, nutritional, and developmental benefits to newborns and their mothers, only a fraction of U.S. mothers are fully breastfeeding their babies by the age of six weeks;
The current maternity care system in the United States does not provide equal access to health care resources for women from disadvantaged population groups, women without insurance, and women whose insurance dictates caregivers or place of birth;

We, the undersigned members of CIMS, hereby resolve to define and promote mother-friendly maternity services in accordance with the following principles:

We believe the philosophical cornerstones of mother-friendly care to be as follows:
Normalcy of the Birthing Process
Birth is a normal, natural, and healthy process.
Women and babies have the inherent wisdom necessary for birth.
Babies are aware, sensitive human beings at the time of birth, and should be acknowledged and treated as such.
Breastfeeding provides the optimum nourishment for newborns and infants.
Birth can safely take place in hospitals, birth centers, and homes.
The midwifery model of care, which supports and protects the normal birth process, is the most appropriate for the majority of women during pregnancy and birth.
A woman’s confidence and ability to give birth and to care for her baby are enhanced or diminished by every person who gives her care, and by the environment in which she gives birth.
A mother and baby are distinct yet interdependent during pregnancy, birth, and infancy. Their interconnected-ness is vital and must be respected.
Pregnancy, birth, and the postpartum period are milestone events in the continuum of life. These experiences profoundly affect women, babies, fathers, and families, and have important and long-lasting effects on society.
Every woman should have the opportunity to:

Have a healthy and joyous birth experience for herself and her family, regardless of her age or circumstances;
Give birth as she wishes in an environment in which she feels nurtured and secure, and her emotional well-being, privacy, and personal preferences are respected;
Have access to the full range of options for pregnancy, birth, and nurturing her baby, and to accurate information on all available birthing sites, caregivers, and practices;
Receive accurate and up-to-date information about the benefits and risks of all procedures, drugs, and tests suggested for use during pregnancy, birth, and the postpartum period, with the rights to informed consent and informed refusal;
Receive support for making informed choices about what is best for her and her baby based on her individual values and beliefs.
Do No Harm
Interventions should not be applied routinely during pregnancy, birth, or the postpartum period. Many standard medical tests, procedures, technologies, and drugs carry risks to both mother and baby, and should be avoided in the absence of specific scientific indications for their use.
If complications arise during pregnancy, birth, or the postpartum period, medical treatments should be evidence-based.
Each caregiver is responsible for the quality of care she or he provides.
Maternity care practice should be based not on the needs of the caregiver or provider, but solely on the needs of the mother and child.
Each hospital and birth center is responsible for the periodic review and evaluation, according to current scientific evidence, of the effectiveness, risks, and rates of use of its medical procedures for mothers and babies.
Society, through both its government and the public health establishment, is responsible for ensuring access to maternity services for all women, and for monitoring the quality of those services.
Individuals are ultimately responsible for making informed choices about the health care they and their babies receive.
These principles give rise to the following ten steps, which support, protect, and promote mother-friendly maternity services:


To receive CIMS designation as “mother-friendly,” a hospital, birth center , or home birth service must carry out our philosophical principles by fulfilling the Ten Steps of Mother-Friendly Care:

A mother-friendly hospital, birth center, or home birth service:

Offers all birthing mothers:
Unrestricted access to the birth companions of her choice, including fathers, partners, children, family members, and friends;
Unrestricted access to continuous emotional and physical support from a skilled woman-for example, a doula or labor-support professional:
Access to professional midwifery care.
Provides accurate descriptive and statistical information to the public about its practices and procedures for birth care, including measures of interventions and outcomes.
Provides culturally competent care — that is, care that is sensitive and responsive to the specific beliefs, values, and customs of the mother’s ethnicity and religion.
Provides the birthing woman with the freedom to walk, move about, and assume the positions of her choice during labor and birth (unless restriction is specifically required to correct a complication), and discourages the use of the lithotomy (flat on back with legs elevated) position.
Has clearly defined policies and procedures for:
collaborating and consulting throughout the perinatal period with other maternity services, including communicating with the original caregiver when transfer from one birth site to another is necessary;
linking the mother and baby to appropriate community resources, including prenatal and post-discharge follow-up and breastfeeding support.
Does not routinely employ practices and procedures that are unsupported by scientific evidence, including but not limited to the following:
IVs (intravenous drip);
withholding nourishment;
early rupture of membranes;
electronic fetal monitoring;
Other interventions are limited as follows:

Has an induction 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, and 15% or less in tertiary care (high-risk) hospitals;
Has a VBAC (vaginal birth after cesarean) rate of 60% or more with a goal of 75% or more.
Educates staff in non-drug methods of pain relief and does not promote the use of analgesic or anesthetic drugs not specifically required to correct a complication.
Encourages all mothers and families, including those with sick or premature newborns or infants with congenital problems, to touch, hold, breastfeed, and care for their babies to the extent compatible with their conditions.
Discourages non-religious circumcision of the newborn.
Strives to achieve the WHO-UNICEF “Ten Steps of the Baby-Friendly Hospital Initiative” to promote successful breastfeeding:
Have a written breastfeeding policy that is routinely communicated to all health care staff;
Train all health care staff in skills necessary to implement this policy;
Inform all pregnant women about the benefits and management of breastfeeding;
Help mothers initiate breastfeeding within a half-hour of birth;
Show mothers how to breast feed and how to maintain lactation even if they should be separated from their infants;
Give newborn infants no food or drink other than breast milk unless medically indicated;
Practice rooming in: allow mothers and infants to remain together 24 hours a day;
Encourage breastfeeding on demand;
Give no artificial teat or pacifiers (also called dummies or soothers) to breastfeeding infants;
Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from hospitals or clinics.
©1996 by The Coalition for Improving Maternity Services(CIMS).

Permission granted to freely reproduce in whole or in part along with complete attribution.


In 2007, The Journal of Perinatal Education published a systematic review of the evidence supporting each of the Ten Steps of the Mother-Friendly Childbirth Initiative (MFCI).The eight members of the Expert Work Group (EWG) that conducted the review were committed to mother-friendly care and had expertise in evaluating and in interpreting maternity care research.EWG members reviewed the entire body of current scientific literature related to each step. Using studies that met pre-determined quality criteria, EWG members provided evidence-based rationales for complying with each aspect of mother-friendly care. For each rationale, they then presented the quality, quantity and consistency of the supporting evidence. Because the MFCI is intended to address mother-friendly care in free-standing birth centers and home birth services as well as in hospitals, the EWG also reviewed the evidence for the safety and effectiveness of out-of-hospital birth. The resulting document, The Evidence Basis for the Ten Steps of Mother-Friendly Care, is remarkable because it represents the first time any individual or group has systematically reviewed an entire model of care. It provides strong evidence supporting the MFCI as the gold standard for maternity care. The document can be downloaded for free from the CIMS website here. Printed copies are also available for purchase through CIMS at a modest cost.