Sheena Byrom OBE with Professor Soo Downe OBE
I found the article above, and one several days later, particularly disturbing. First of all, the harrowing stories of where a family has lost their baby are beyond shocking for the reader. There are no words to express the intense, life-changing grief those involved are feeling. I must mention the health professionals involved, also. I am fully aware of the trauma for them too. No-one working in health care services goes to work to do harm, and the suffering when mistakes are made is also traumatic and devastating. Yes, there needs to be learning from incidents, and development where needed. But blaming one professional group, or a particular type of birth, does little to improve any situation.
Why does 'normal birth' matter?
A review of all the relevant studies of what matters to women, from around the world, including the UK, has found that: Women want and need a positive pregnancy experience. This includes: maintaining physical and sociocultural normality; maintaining a healthy pregnancy for mother and baby (including preventing and treating risks, illness and death); effective transition to positive labour and birth; and achieving positive motherhood (including maternal self-esteem, competence, autonomy) [Downe S, et al 2016].
The issue here is increasing sensitivity, in the press and among politicians, a few activists, and health care providers, to the word ‘normal’. All these studies made it clear that the vast majority of women want to go through pregnancy, labour, birth, and the postnatal period relying on their own capacity to grow, give birth to, and nurture their babies themselves – ie, in the usually accepted sense of the word, ‘normally’. Indeed, supporting women to achieve this as far as they want and are able to do so, while helping them and their babies to be as healthy as possible, is the fundamental function of ‘midwifery (Lancet Midwifery, 2014).
However, it seems that the term ‘normal birth’, and all that it relates to, is being rapidly relegated to a rarity in practice, or even (negatively) to cult status among the media and other powerful stakeholders (who are mostly not childbearing women, it should be noted). I regularly spend time with student midwives from around the UK and beyond. They tell me they are worried about practising as qualified midwives, as, during their training, they hardly ever see women who have had a normal, physiological, straightforward pregnancy, labour and birth. This section of a letter the RCM received from a student midwife in 2014, summarizes these concerns.
'However, I became very disheartened and concerned about my own experiences. As a student midwife, I completed my second year of training after having witnessed and participated in 52 caesarean sections, 16 instrumental deliveries and very sadly, only 11 normal deliveries. I can vouch for the fact this story is not unique and many students are having a chronic lack of exposure to normality. In fact what the International Confederation of Midwives and Royal College of Midwives seemed to call 'normal', to me seemed like a fantasy, not the world in which I was training and learning. I was saddened to realise that I'm now a third year student and have never used intermittent auscultation in practice and have never seen a women give birth off her back'. Student Midwife to RCM 2014
The situation remains the same three years on, or potentially worse.
How are student midwives and eventually midwives able to support women to achieve what they want to achieve, AND call for assistance when there is a deviation from the normal, if they have never seen it?
Recent press reports add to the fear already embedded in maternity services. This fear is real in high income countries (Shaw et al 2016), and influences the decisions of women, mothers and families alike. Many maternity units in the UK are being challenged by the Care Quality Commission to increase their normal birth rates, and to reduce their induction and CS rates. If the culture of the organisation is to intervene ‘just in case’ out of fear, and to avoid litigation, recrimination and negative press- how do they achieve these targets? And if there is a widespread problem where midwives 'pursue normal birth at any cost', why are the statistics below so stark? Surely, the opposite would be the case?
The term ‘normal birth’, and all that it means, has been debated for years. Some have argued for alternative terms, that are seen as less judgmental (though it isn’t clear if women have been asked if they are being judgmental when they talk about their normal birth). These alternatives include terms such as natural, physiological, uncomplicated, or straightforward. However, the term ‘normal birth’ is used by the World Health Organisation and Scotland's recent directive for future maternity and neonatal services. We believe the term will be used by the new digital data collection system that will be set up as part of the implementation of England's Better Births report. It is on the list of terms that the EU think should be used in this context, it is in the title of the international normal birth research conference, (which has been running successfully for 12 years around the world). We don’t have a problem talking about normal weight, or normal urination, or normal breathing. It seems very strange that ‘normal’ childbirth, in contrast, should be so very contentious for some commentators in this area.
WHO says that 80% or more of women should be able to give birth normally around the world (which means more should be able to do so in the UK, given the overall level of health in the UK as a high income country). The fact that only about 35% of women are supported well enough to actually achieve this in the UK (and that many of the remaining 65% feel failures as a consequence) is an indictment of our maternity service provision, and not of women themselves. If we actually were successful in supporting women to achieve the rates of physiological birth that should be possible for them, at the same time as helping the small minority of women for whom this is not possible to feel positive about the interventions that are really needed for themselves and/or their baby, we would not be in the position we are in now, where normal is seen as something exotic that should not be promoted.
There does not seem to be much debate about the move to increase breastfeeding, for the wellbeing of mother and baby in the short and longer term. It does seem strange, then, that there is so much debate about any project to increase rates of normal birth, for the same public health reasons (and, indeed, for reasons of improved mental health, for mother, baby, and family). It seems that we might be being distracted with this debate, when the underlying issues are much more about the continuing undermining of women’s confidence in their bodies and in their ability to grow, give birth to, and mother their babies. Indeed, the pressure, in contrast, seems to be in the opposite direction, as women are increasingly being persuaded to buy in to monitoring, technical intervention, and the need to meet narrow standardised ‘norms’ (that are not physiologically ‘normal’ for them as individuals), which, in turn, makes them more prone to a diagnosis of ‘(potential) abnormality’, which renders them increasingly unable to believe in their own capacity – and so on, in a vicious cycle that actually increases risk for mother and baby.
A moral and ethical imperitive
The debate seems to have become polarized as ‘either a healthy baby OR a normal birth’. The vast majority of women want both. While it is right to ensure that as many women and families have a baby that is healthy, it is equally right to work towards ensuring that as many women and families as possible have a birth that is as physiological as possible. Promoting normal birth while also maximising the wellbeing of mother and baby is therefore not a cult, or a professional project, or a conspiracy. It is a moral and ethical imperative, that should be supported by all of those with any interest in the wellbeing of mothers, babies and families, in the short and longer term. This includes professionals, journalists, politicians, health service managers, childbirth activists, and lawyers.
It is very far past time to turn the tide.
Downe S, Finlayson K, Tunçalp O, Metin Gülmezoglu A 2016 What matters to women: a systematic scoping review to identify the processes and outcomes of antenatal care provision that are important to healthy pregnant women. BJOG. 123(4):529-39
Shaw et al (2016) Drivers of maternity care in high-income countries: can health systems support woman-centred care? The Lancet Vol 388 No 10057 Available at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31527-6/fulltext