Normal birth - a moral and ethical imperative

Updated on the 14th August, 2017 

It has been a very troublesome weekend. 

Using old news, from one particular source, the UK press have run with a story based on the above press cutting. Same information - except the click-bait used was that midwives were to stop promoting natural childbirth, and the Royal College of Midwives had removed their Campaign for Normal Birth site, and were 'dropping' the use of the term 'normal birth',  Right, now I want to make some things clear.

1. The Royal College of Midwives discontinued the Campaign for Normal Birth (CNB) THREE YEARS AGO. I was actually part of that decision, and it was due to the fact that the College felt it was important to encompass antenatal and postnatal care within the initiative, and public health. So 'Better Births' was born. It had nothing to do with the Morecambe Bay Report, which was published after the decision had been made. But even though the 'Campaign' ceased, the support for normal birth has not. The RCM have a normal birth resources page. Some of the resources developed for the CNB have been removed following a request, and will hopefully be replaced with more up to date material. Since writing this post, Cathy Warwick CBE, CEO of the RCM, has written to confirm the College's continued position to support midwives to promote and facilitate normal physiological birth. 

2. THERE IS NO EVIDENCE that the RCM's Campaign for Normal Birth had any direct influence on the tragedies that occurred at Morecambe Bay, or any other service. The adverse events at Morecambe Bay were attributed to five elements of dysfunctionality, one of which was the 'over-pursuit of normal birth'. The report does not apportion blame to any one of the five individual elements, but to the whole five. In any case - why is the one element linked to resources supplied by the RCM? 

3. I believe in choice, autonomy, and safety. Out of our 9 grandchildren, none have been born 'normally'. They needed expert medical intervention, medical support, and I am eternally grateful for the attention they received. I also understand the evidence that physiological normal birth is the optimal way to give birth for most women, and that most women want it.  

4. I hear and fully respect that some women feel that the word 'normal' in relation to birth is divisive, and upsetting, leaving them feeling like they 'failed'. I can understand this, that women may feel disappointed if they wanted a particular birth experience, worked towards that goal, then it didn't happen. But that's it. I would like to suggest that it is the end result is the disappointment, more than the word. Would women feel less disappointed if birth was called physiological? I liken this debate to infant feeding. If a woman has problems and ceases to breastfeed her baby, she feels disappointed - no matter what the term is. Normal birth is a normal physiological bodily process - as is normal respiration, and digestion. The terms physiological, natural and any other are fine too, but let's not blame a word for disappointment. We need to listen to the experiences of women when they are unhappy with their birth experience for whatever reason, then aim to change services so that optimal childbirth is the goal, for a healthy mother and baby. I will not stop using the term 'normal birth' and I will support midwives to facilitate women's choices safely, 

The reasons why I say this are in the original blog post, below. 

May 2017

Sheena Byrom OBE with Professor Soo Downe OBE

I found the article at the top of this page, 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).

“the term ‘normal birth’, and all that it relates to, is being rapidly relegated to a rarity in practice...”

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? 

“We don’t have a problem talking about normal weight, or normal urination, or normal breathing”

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. 

References:

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

Lancet Midwifery Series (2014) 

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

'Keep fear out of the birth room': an interview with Professor Hannah Dahlen

When I first heard Hannah Dahlen speak, it was in Grange-over-Sands, England, at the Normal Birth conference. Hannah gave a talk on the 'Juggernaught of Intervention', describing the potential consequences of unnecessary medical intervention in childbirth,  and  I was hooked. Each of Hannah's words rang true to me, I was, and still am, concerned about the ever increasing focus on 'risk' in maternity services, and the impact this is having on childbearing women and those caring for them.    Since then I have followed Hannah's brilliant work, via academic publications, with enormous interest. After the success of interviewing Prof Soo Downe OBE and Dr Helen Ball, I asked Hannah if she would be willing to participate too. I am thrilled that she said yes! Hello (or G’day!) Hannah! Thank you for agreeing to be interviewed... could you introduce yourself, please?

Hi Sheena, my name is Hannah Dahlen and I have been a midwife for nearly 25 years. I am currently the Professor of Midwifery at the University of Western Sydney, which is in NSW, Australia. I am also a practising midwife and I work with five other lovely midwives (Robyn, Jane, Janine, Emma and Mel) in the largest private group practice in NSW, called Midwives@Sydney and Beyond. I provide continuity of care for women throughout pregnancy, labour and birth and for six weeks following the birth. Around 90% of our women give birth at home. I am also the national media spokesperson for the Australian College of Midwives, which means I can be woken up as early as 5am to tiptoe through political landmines as I try and represent midwives in the best possible light. Once I did a radio interview at 4am and had a very funny time talking to truckies about birth, as apparently they are the only ones awake at that time. I am also on the executive committee of the NSW branch of the Australian College of Midwives and I have held this position for 17 years.

When did you realise you wanted to be a midwife? 

I don’t remember realising that I wanted to be a midwife because I can’t remember ever wanting to be anything else. My mum was a midwife and I grew up Yemen, where I was also born. My earliest memories were being cordoned off in a playpen in the corner of the clinic with a kidney dish and tongue depressor to play with as my mum worked. I also remember being sat on a tin in a backpack so I could see the countryside as mum and dad trekked into the villages to vaccinate people. Because I was so blond and fair skinned and had vivid blue eyes the Yemeni people found me fascinating and my hair was always being pulled to see if it was attached to my head. When I squawked in protest they concluded I must be a wizened up old woman with white hair. But of course there was a moment that I knew without a doubt the kind of midwife I would be when I was 12 years of age. My next door neighbour gave birth to her third child and I helped the local midwife catch the baby. When my neighbour saw it was another girl she turned her head away and said , ‘take it away.’ She feared that her husband would divorce her or take a second wife as she had not produced the much valued son yet. I remember carrying this perfect little girl, which they named Hannah after me, to the window as the dawn was breaking and the minarets began their melodic calls to prayer. I remember as girl on the brink of womanhood feeling both spellbound by the miracle I had witnessed and outraged that girls should have less value than boys. I knew then that you could not be a midwife without fighting for women’s rights and that was when I think the political passion I consider inextricable from the job of midwifery was born. I believe if you are apathetic about women’s rights then you are not cut out to be a midwife and if you are frightened to be political then choose another career.

What does a typical day in your working life look like?

Gosh, I have no typical day, as that sounds too much like the definition of boredom. My life is often very eclectic and unpredictable. I get to work about 9am after putting my youngest daughter on the school bus and then I might be doing several things, such as teaching, undertaking research, going to meetings, answering telephone calls from journalists or the women I care for. I have lots of wonderful PhD, Masters and Honours students who give me such delight, as I love growing the future of our profession, and they are indeed the future. I might end my day with a postnatal or antenatal visit in a woman’s home, and if I get called to a birth it is usually at night. I have only had to get someone to fill in for me once in the past four years of being on call because a woman gave birth when I had a lecture on. Once back home I do what all mothers do: get the dinner on, nag about homework, listen to stories of the day and hopefully collapse on the lounge to watch Call the Midwife with my daughters, or Modern Family, which is another favourite.

I am a great advocate of your work on how the ‘risk agenda’ is influencing maternity care. Can you tell us why this is so important to you?

Fear is ruining birth and we have to stop the fear. When I am asked what I do as a midwife I say my job is to keep fear out of the room. I knit at birth now and work very hard to keep fear at bay in my own practice. I left the hospital system after 20 years of practice because I recognised I had become undone by the fear that was manufactured around me and I was no longer providing women with the best care. Now that I work in private practice and out of the system, supporting women mostly to give birth at home, I have re-found my faith in birth and realise it is not birth that is dangerous, it is us! I love working with midwives on how to put risk in perspective and manage the fear that is so endemic in our maternity systems. We need to make friends with fear and work out when it is protecting us and when it is destroying us. We also need to stop blaming women for their fear as I think the models of care, attitudes and language of health professionals are most to blame. I love watching women give birth without fear now, surrounded by love and trust. Women are so amazing and we are so lucky to share this magic journey with them and their partners and families.

We have a situation where maternity services are focused on risk reduction, and yet outcomes aren’t improving. What do you think the answer is?   

Get women and midwives out of the hospital. Move back to primary health care, community based models. Give every woman a known midwife and make relationship based care the priority. I often say to my students the largest organ involved in childbirth is the brain not the uterus. If you want the uterus to function well then start working with the brain. Value women and value birth. Base practice on evidence and make health services accountable to the evidence and provide cost effective care. In Australia we have been calling for private obstetricians to make their caesarean rates public so women know when they are cared for by a doctor with a 90% caesarean section rate. In my country I think this would have a big impact on our caesarean section rate which is nearly double in the private sector. Lastly, and most importantly, if women are to trust in themselves and birth then surely those caring for them need to trust in women and birth.

What other areas of maternity care are you interested in?

Just about everything, this is my problem. My mother always said the worst thing you can do with Hannah is make her bored. I can promise you one thing there is nothing about being a midwife that is boring. I say my job is perfect because I combine teaching, research, clinical practice and politics together. I would hate not to believe in what I do and I really, really do believe in the amazing job midwives do. I would love to see my colleagues hold their heads up high and say ‘I have the most amazing job in the world’, after all we usher in the future! I really love history as well, as I am convinced that the past has much to teach us and some really good midwifery practices happened in the past. This is why I chose to undertake a randomised controlled trial looking at the effect of perineal warm packs in second stage for my PhD, as it was branded an ‘old wives tale’ with no evidence to support it. This so called ‘old wives tale’ is now Level 1 evidence. It does give me a thrill that amidst all the ‘machines that go ping’ a midwife can hold her head high as she walks down the corridor with a bowl of steaming water and flannel to give a woman in second stage comfort. I am also very interested in how birth is shaping society and founded the group EPIIC (Epigenetic impact of Childbirth) with Professors Soo Downe (UCLAN) and Holly Powell Kenney (Yale) in 2011. I think this is where we need to really channel our energy in the future. If the way we are born is re-shaping society, which is increasingly looking likely, then we need to urgently get the message out before it is too late.

What are your plans for the future Hannah?

I never think about the future and I never really have. I never thought I would do a PhD - I kind of fell into that. I never thought I would be a professor and that just seemed to happen. I believe in doing what I love and believing in what I do and whatever eventuates usually is a good thing. But most important of all you sleep well at night when you adhere to this philosophy - that is if the phone doesn’t ring to call you to a birth of course. Best of all I can honestly say I have no regrets. Every part of my life, even the sorrows and mistakes have made me who I am and provided me with such valuable lessons.

And lastly, what inspires and motivates you to be proactive what you do?

Women’s rights motivate me and making the world a better place.   None of us should come into this world and leave again without making the world a better place. Until we do right by women and recognise, value and facilitate their amazing role in society then everything we do will be incomplete. The hand that rocks the cradle does rule the world whether the world is willing to acknowledge it or not. When every girl baby is born into the arms of parents who want her as much as they want their sons then we will be on the way to bright and certain future. In many ways I feel today that I am still that 12 year old girl standing by the window in the dawn light gazing at that perfect little girl, spellbound and outraged but always full of hope that we are on the way to a brighter future.

Hannah, thank you SO much for taking time to tell us more about yourself! It's such an honour having your input into my blog….I am thrilled!

You can follow Hannah on Twitter:  @hannahdahlen

And her website: http://www.uws.edu.au/fach/fach/key_people/associate_professor_hannah_dahlen

Photograph by Holly Priddis

England needs more midwives: but legal services are fine

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I was interviewed on Radio 5 Live yesterday, in relation to the news coverage of the National Audit Office revelations of maternity care.  The report confirmed the fact that England IS short of midwives, and revealed that the NHS spends nearly £700 on clinical negligence cover for each live birth in England. I wonder how many times audits and reports will confirm what we midwives have known and shouted about for years, and how long the message will continue to fall on deaf ears.

The Royal College of Midwives,  National Childbirth Trust, AIMS,  Women’s Institute and other organisations have campaigned long and hard for more midwives, needed urgently for the rising birth rate and increasing complexity in caring for mothers and babies. But there is something else going on here. The financial implications of England’s current negligence insurance scheme (Clinical Negligence Schemes for Trusts) mentioned above are bad enough, but associated processes also significantly increases the workload of maternity care staff, and adds to the growing culture of fear in maternity services.

In an attempt to increase safety through implementing standards of compliance, activity related to the scheme potentially increases risk by putting extra pressure of individual members of staff. ‘Tick box’ activity, extra form filling, and duplication of records add to the human cost and potential for mistakes. In many organisations midwives are taken out of generic posts to work as ‘risk midwives’ or governance leads. Usually these midwives are highly competent clinically, and their absence in the clinical area is missed-adding to the risk.

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However, an important impact of our legal system is related to practitioner's fear of recrimination, and fear of litigation. Defensive practice or ‘covering your back’ ‘just in case’ is a recognised symptom of fear of litigation-and subsequent over treatment increases the risk of iatrogenic harm.  The increased and often duplicated recording of information becomes the focus of ‘care’, as practitioners complete patient records which are audited for insurance purposes. What the carer writes becomes more important than what she/he does, and women and families increasingly experience this distraction negatively.

The medical negligence solicitor who took part in the radio programme with me yesterday, said midwives and doctors need to increase their skills, and he suggested that England’s medical negligence processes were the envy of the world. I have a different opinion. Ensuring safety through appropriate skills is crucial, and whilst mistakes will happen, there is no excuse and we should continually aim to learn from mistakes,  and work on improving services. Along with others, I believe improvements will only come if NHS workers are sufficient in number to have time to care, and that they are supported and nurtured enough to feel safe themselves. Where fear prevails and defensive practice in normal, women and families will continue to suffer. Radical but carefully planned changes are needed. Malpractice claims are rising, and there is little evidence that safety is improving, despite the laborious and bureaucratic systems and process imposed in the name of such. Our negligence claims insurance schemes aren’t working, and midwives are on their knees. Even though politician Dan Poulter is an obstetrician by profession, his responses to the NAO report reveal limited insight into the detail underpinning the facts that matter. We’ve said it before many times. If we don’t get it right for mothers and babies at the beginning of life, the impact can last a lifetime.

Childbirth has far reaching public health implications. This specilist medical negligence solicitor reveals the fact that many of the claims she sees are the result of pressures within the maternity systems, and calls for more resources to be invested.  Maybe it’s time to revisit a no-fault compensation scheme, the attempt in 2003 was never taken forward. Scotland has pursued this in light of the success in other countries.

Whatever we do, we can’t continue in the same vein. I would love to know your thoughts.

Why is the birth room being used for mass entertainment?

I don't like this photograph. It actually depicts the worst possible scenario. That is, a labouring mother flat on her back, vulnerable with her legs wide open. The midwives hold the power. As a midwife this is certainly not how I want my profession to be represented.

I imagine that the photo was taken to attract media attention, to draw potential viewers to the BBC TV programme it is associated with...and there will be those who don't notice the image particularly. But there is a message in the pose that has the potential to negatively influence society, and childbearing women. As the documentary programmes have too....ITV's One Born Every Minute, and BBC's The Midwives.

I have to admit that I always avoid watching TV documentaries about maternity services. My decision stems from the fact that I can’t bear to watch poor midwifery or obstetric practice without the ability to influence, and I think the intimate moment of a baby’s birth should take place in a private ‘space’ where the woman feels safe and protected. It certainly isn’t the place for TV cameras, even those that are hidden.

Childbirth is important for humanity, and the ultimate aim of maternity care workers is to ensure women have a positive childbirth experience. When women are in labour the hormones that aid the birth process are heavily influenced by the environment she is in.  Michel Odent, a highly acclaimed French obstetrician gives his expert opinion; one which I fully support after observing childbirth first hand for 35 years. He said:

The best environment I know for an easy birth is when there is nobody around the woman in labor but an experienced midwife or doula – an experienced mother figure who is there, and who can remain silent. Silence is a basic need for a woman in labor. Privacy is another basic need. Michel Odent

So that's a big enough reason not to have cameras in the birth room that broadcast private and intimate moments to millions, with no control over who watches.

And then there's the issue of editing. The producers want to draw viewers in with drama...and the drama is having the desired effect and the viewing is said to be 'compelling'...but what else is happening?

Globally, we are in a situation where women are becoming increasingly afraid of childbirth and unsure of their ability to give birth without medical assistance. There are lots of factors that influence this position, and the media play a huge part.

As a Facebook and Twitter user I have read so many comments in response to the midwifery documentary programmes, from mothers, women, midwives and student midwives. The comments mostly demonstrate the fact that the content of the programmes have stimulated fear. Some midwives, whilst acknowledging the scary and distressing scenes highlighting their colleagues 'under pressure', believe it to be good as it raises the issue of the shortage of midwives nationally. But should this be at the expense of those potentially and actually using maternity services?

Let's read the comments.

The Telegraph reviewed The Midwives

There is a gruesomeness to childbirth TV that I find partly compelling and mildly horrifying. I understand that births where nothing goes wrong don’t make for exciting enough footage but, as a childless, slightly broody 31 year-old, I found some of the scenes pretty harrowing, and had to watch with my fingers over my eyes. There were complications with almost every birth – is this the BBC’s attempt to keep that soaring birth rate down? If so, it’s certainly worked on me… 

One tweet from a student midwife said that she was scared to go on her next shift following the programme....

Twitter:

'It seems such a shame they always show midwives shouting at women, calling them good girls, or do the 'silent midwives' not want to be on TV…'

Facebook (taken from One Born Every Minute-the truth page)

Susan:

'I watched it last night and couldn't believe the triage midwife with the short blonde hair telling the soon to be mother of 5 that she was definitely not in labour. It was her fifth baby, she knew her own body!! I wanted to shout at the telly. I was so smug when the labouring woman progressed quickly and birthed not long after that. I did not like that midwife's manner at all, and she only seemed to get worse throughout the programme..'

Jane:

'I am 21 weeks pregnant with my third baby, and watched the first programme last night. Honestly, despite having been very lucky both other times, it has left me petrified. Must get a sense of perspective....'

Oh dear. How to demoralise women.

We really need to turn the tide. In addition to #moremidwives we need some positive media....positive stories to raise the bar. What do you think?

P.S. On the contrary, I LOVED Call the Midwife. Quite different.

Photograph