Normal Physiological Childbirth - the debate goes on...
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I am continually dismayed with polarised debates on social media about this topic - going round in circles leaving a degree of frustration and potential fear.
Recently I was alerted to a thread on Twitter where individuals are condemning organisations, particularly universities, where learning modules are on offer supporting or promoting normal physiological childbirth. Rather than try to respond to tweets with insufficient space and ability to expand, I am writing this blog post. I will draw on evidence already published on the topic and the words of experts in an attempt to clarify why such programmes are not only necessary but crucial - if we are to improve safety within maternity services and increase the potential for enhanced maternal and child health outcomes both in the short and long term.
Let’s consider the facts about normal, physiological birth:
According to the evidence most women want a physiological labour and birth.
For midwives:
- necessary as part of midwifery degree regulation and UK’s Nursing and Midwifery standards
- to meet international standards of midwifery education
- that ongoing postgraduate education in this field is a legitimate and necessary part of ensuring that women and birthing people and their babies have safe and positive maternity care that is appropriate for them if they choose physiological labour and birth.
- Not only is physiological birth the mode of birth most women want, but it is also the mode of birth most women in the world have – and care for these women must be safe. Therefore midwives and students must learn how to keep it safe. If midwives do not learn about physiological processes, it will make women LESS safe – introducing increased risk for the majority of women who have physiological births, and making it harder for midwives to identify deviations from normality (and therefore making it less safe for women and babies with complications).
In correspondence relating to NMC standards (2021), Professor Mary Renfrew stated:
..’the NMC standards of proficiency for midwives set mandatory standards for all UK midwives as well as for the education of students. They were set through an extensive process of evidence review and consultation and engagement with more than a thousand individuals and organisations, and they align with international standards. These standards make it clear that a) promoting/supporting normality is a core part of midwifery requiring knowledge and an essential set of skills, and b) that women’s decisions are fundamental, and c) that midwives are key to interdisciplinary collaboration and partnership working when complications arise. For women and babies to be truly safe, they need midwives with the knowledge, understanding, and skills to practice in this way, and who are supported and enabled to do so.
Normality is clear throughout these standards – in the role and scope of practice of the midwife, in the key themes, and in specific Domains and individual standards - as examples see the Introduction, Domain 3b (eg 3.12), 3c (eg 3.24, 3.25) and Domain 6 (eg 6.21, 6.65), but there are relevant standards throughout - recognising that normality matters not only for birth but throughout pregnancy, labour and birth, postpartum, and the early weeks of life - as well as more descriptive/specific standards such as ‘promote the woman’s confidence in her own body, health and well-being, and in her own ability to be pregnant, give birth, build a relationship, and nurture, feed, love, and respond to her newborn infant’ (6.14). In addition to midwives’ key role in supporting and enabling physiological processes, there are of course detailed sections on the midwife’s role in recognition and deviation from normal processes and effective actions when needed in the context of interdisciplinary working (Domains 4 and 5a) – the standards make it clear that collaboration with medical colleagues and others, and rapid effective action when needed, are essential for women and babies to be safe at all times.
The broader context of the standards matter – no individual standard can be seen out of context – importantly, they have a strong focus throughout on safety (which includes physical, social, psychological, cultural, spiritual aspects for both woman and baby), on building relationships with women, partners, and families and sharing complex information (including sensitive, individualised conversations, listening and responding to women’s concerns and decisions), as well as professional accountability and the use of evidence. The standards are all based on a human rights perspective (1.3), and set within the context of ‘always working in partnership with women, basing care on individual women’s needs, views, preferences, and decisions, and working to strengthen women’s own capabilities to care for themselves and their newborn infant’ (1.13).
In addition, on the 17th September 2021, the International Federation of Gynaecology and Obstetrics (FIGO) published an ethical framework for respectful maternity care during pregnancy and childbirth which states:
Maternity care must be supportive, individualised and value-based – it is best served as a partnership model between health care practitioners and the 'MotherBaby–Family'.
Health care practitioners are expected to routinely provide maternity care for mother, baby and family – they must ensure that their practices are driven by health needs and expectations, as well as by health outcomes and cost-effectiveness based on optimising the normal processes of childbirth.
Health care practitioners are expected to follow evidence-based practice – they will promote practices proven to be beneficial in supporting the normal physiology of labour, birth and the postpartum and neonatal periods.
Professor Soo Downe added:
‘It is understandable that individuals who feel they have not been supported in their decision making (either around spontaneous labour and birth or around wanting to have a specific intervention) may feel that education and training should be focused on the kind of care they wanted or needed, and not on any other alternative. But maternity care is about both-and: both understanding pathology and treatment, and about understanding physiology and how to preserve it. To deny professional staff the education they need in physiology and in safely preserving the physiological processes that are the norm for the majority of human beings (normal pregnancy, normal blood pressure, normal fetal development as well as normal labour and birth) is as dangerous as to deny professionals the education they need in pathology and treatment, so they can effectively support those who need or want safe and personalised interventions.
For the sake of all women, birthing people, babies, families and partners, It really is long past time for all of us to stop sniping across lines of division, and to truly, authentically, have a dialogue between us that properly listens to, values, and educates for the whole range of maternity care that service users need and want. This includes education, training and updating in the knowledge and skills needed to support normal physiological processes, as well as in recognising and responding to the need or desire for intervention’.
We wait in anticipation for the results of the Re:birth project being led by the RCM and RCOG. If the issue is in the wording used and not the content of university programmes, then maybe it’s a compromise we have to make. If the conclusion is that ‘optimising normal physiological processes’ is the preferred term, then we can get on with supporting midwives and obstetricians to do just that, and to enable them to provide safe, evidence-based maternity care.