The backlash against Normal Birth by Beverley Lawrence Beech
At an AIMS AGM it is customary for the Chair to give an account of the activities of the Committee during the year. I am not going to do that this year because, unlike any other year, there has been a concerted campaign, by those who do not understand what a normal birth is, to demonise ‘Normal Birth’ and undermine the efforts of midwives, obstetricians, doulas, childbirth educators and others to enable more women to achieve a ‘Normal Birth’.
For the first time ever, in England, the government has recognised that childbirth has become over-medicalised and through the National Transformation Council, led by Baroness Julia Cumberlege, has sought to create a framework that will, with the support of obstetricians and other clinicians, enable midwives to practice midwifery, encourage and reduce the amount of unnecessary medical interventions in childbirth.
Questions about ‘Normal Birth’ began to be raised following an article I wrote in the AIMS Journal in 1997 asking whether or not normal birth existed. In 2001, Soo Downe published her prospective cross-sectional prevalence survey of five consultant units in one region to establish the percentage of births which were termed ‘normal’ or ‘spontaneous’ but which in fact involved one or more of a specific set of interventions. She found that only one in six women expecting their first baby and one in three women expecting subsequent babies had a ‘normal’ birth (Downe S, McCormick C and Beech BL, 2001). Some years later the Royal College of Midwives joined the campaign and produced guidelines to encourage midwives to focus on normality.
In March 2015 Bill Kirkup published the report of his investigation into the maternity and neonatal services at Morecambe Bay NHS Foundation Trust from January 2004 to June 2013. He exposed a dysfunctional obstetric unit where there were tensions between the staff, over use of interventions and also the mis-application of physiologically normal birth. None of these is right, but the ill-informed have focused on demonising normal birth, aided and abetted by the media which is ever alert to a sensational issue.
One of the latest manifestations of this has been the article in The Times Magazine (2 Sept 2017) the ‘Nightmare on the maternity ward’ by Natasha Pearlman which paints an all too common scenario of Natasha’s traumatic labour and birth, claiming a ‘Childbirth Conspiracy’ but focusing on the wrong target, as it failed to understand the difference between a normal birth and the medicalised experience of the majority of women.
For example, the waters break and the woman rushes off to her local large, centralised, obstetric unit. Once there she is told that she is not in labour and advised to go home. Some women insist on staying and are then left in a side room, alone and with frequent contractions, or are pressured into agreeing to an induction or acceleration for lack of progress, and before long is given morphine to deal with the increased pain. Eventually. after endless hours of painful contractions, with little or no support from a midwife (who is likely to be rushing between a number of other women) she is sent to the labour ward, to face more hours of labouring alone. Invariably, an epidural is set up, and she ends up pushing the baby on command (because epidurals affect the muscles and the woman has no idea of whether she is having a contraction or not), lack of progress occurs, and a forceps delivery, or an emergency caesarean, ensues. A not un-common scenario for a ‘modern’ birth, where fewer than one in ten women will have a ‘normal’ birth. The result of all this is a traumatised woman who wanted a normal birth, who then believes that the ‘campaign for normal birth’ is misguided because no-one has explained the real reason why she did not have a normal birth.
No-one explains that leaving her home might reduce her chances of having a normal birth, or that a normal birth in a large, centralised, obstetric unit is unlikely, or that in the majority of these units the midwives are too over-worked, understaffed, and expected to comply with overweening rules and regulations. Furthermore, being required to keep copious notes and adhere to local protocols, that are interpreted as rules, leaves little or no time to support women to birth normally.
Skilled, safe, midwifery that supports women to have a normal birth, or seeking appropriate medical help when needed, involves a midwife getting to know the woman during her pregnancy, gaining her confidence, understanding her worries and intentions, quietly observing the progress of a labour, and intervening only when there is a need. A far cry from what is happening in many obstetric units where midwives are not able to practice as they want.
Expecting to have a ‘normal birth’ is not like ordering a leg of lamb from the butcher. Women are obliged to research and understand what a normal birth is and what conditions are needed in order to enable them to birth normally. We grossly underestimate the impact of being mammals, and how we are significantly affected by our hormones. When the conditions are not right for birth the birth can become difficult, and we have developed a maternity system that too often creates conditions that makes birth as difficult as possible. My grandfather was a farmer, and he sat up all night with an elderly mare because he was worried about her foal. At three o’clock on a very cold night he decided that he needed to warm up, went to the farmhouse for a cup of tea and, when he returned there was the foal. The mare had waited until he was out of the way before she gave birth. We humans are little different, we are very affected by our surroundings and those around us.
If birth is to go well, there are a number of crucial conditions that need to be fulfilled: Women need to be in a place where they feel safe, attended by someone they know and trust, be in a calm environment and remain undisturbed. Few of these conditions are met in large, centralised, obstetric units. The woman is likely to be moved from room to room, the labour is likely to be interrupted frequently, either by frequent checking and monitoring or by strangers entering the room. Women in labour are very sensitive, and if it is their first labour, and they have an anxious and nervous partner, that nervousness is picked up by the woman, and it can significantly affect the progress of labour. Most women and their partners need the calm reassurance of a known and trusted midwife.
Too often women blame themselves for what they perceive as their ‘failure’ instead of understanding that the real failure lies with the current system of centralised, over-medicalised, care that fails to provide women with the support they need to enable them to have a normal birth. The NCT is often criticised for focusing on ‘normal birth’ and presenting a positive picture of birth; my criticism of the NCT is that it fails to tell women what the chances of a normal birth are if women must birth in a large, centralised, obstetric unit. Of course, there are midwives in those units who do their very best to support and help women to birth normally, but in far too many units they are under enormous pressure to conform to the protocols, and are very short staffed.
Examination of good evidence reveals the far better physical and emotional outcomes for women and babies when they have continuity of midwifery care, and are supported to birth in their own homes or free-standing midwifery units. The Better Births in England strategy has recognised this and has set up mechanisms to enable Trusts to change the way they provide care so that more women will be able to have normal births, and fewer women will be traumatised. It is thanks to endless newspaper articles, television programmes, such as One Born Every Minute, and other negative propaganda that women fail to understand what a normal birth is. Sadly, many women who achieve a normal birth are reluctant to talk about it, either because of the hostility they encounter or because they do not want to upset those who have had traumatic experiences.
Journalists and others should be investigating how it is that so many fit and healthy women can go into hospital have an horrendous birth experience and leave physically and psychologically damaged. Blaming normal birth takes the focus off the real problem of inappropriate routine medicalised care for healthy women and babies and a shortage of skilled midwives who are supported, enabled, and encouraged, to practice midwifery.
After 40 years as Chair of AIMS I have chosen this year to resign. I joined AIMS as a result of experiencing the kind of medicalised birth I have described earlier, and it is deeply troubling that 40 years later there are even more interventions than there were then and, even more disturbing, women’s confidence in their ability to birth their babies has been seriously undermined by a climate of fear and a mis-applied focus on risk. I hope that in the next 40 years my successors will be able to encourage a climate of confidence and professional co-operation in birth that will result in more women experiencing normal birth and getting the support they need to achieve it.
Beverley A Lawrence Beech
Association for Improvements in the Maternity Services
23rd September 2017
Downe S, McCormick C and Beech BL (2001). Labour interventions associated with normal birth, British Journal of Midwifery, October 2001, Vol 9, No10, p 602-606.
Kirkup B (2015). The report of the Morecambe Bay investigation, The Stationery Office, ISBN 9780108561306