NORMAL BIRTH - evidence and facts

"Yellow journalism is is a type of journalism that presents little or no legitimate well-researched news and instead uses eye-catching headlines to sell more newspapers'' 

I would usually add screen grabs of the offending news articles HERE, but I am not. They are sickeningly inaccurate and offensive. 

But this post is referring to recent ludicrous press claims in several newspapers, of a non-existant 'cult of normal birth' by midwives, and that mothers and babies are suffering because of it. These stories are fear-mongering untruths, aimed at damaging a profession, and limiting women's autonomy and choice. And, they are adding to the fear amongst pregnant women, that already prevails. 

Shame on you all.

Professor Soo Downe OBE, midwife and internationally recognised expert in the field of childbirth, presents the

EVIDENCE AND FACTS

1.       There is no evidence whatsoever that a ‘cult of normal birth’ exists: indeed, less than half of women in the UK who could have a normal birth do so (40% as opposed to 80%), and nearly  double the World Health Orgnaisation (WHO) recommended rate of 15% of Caesarean section (CS) are being done (over 26%) at a time when the whole world accepts that CS rates are too high, and that high rates risk harm to mothers and babies.

2.       The Morecambe Bay Report seems to be the sole source for all this reporting. This described the situation in one hospital (not a midwife led unit) in one Trust in one part of the country some years ago. Dr Kirkup, who  authored  the report,  has reiterated that there were five areas of failure found – the issue of normal birth was only one of them. He has emphasised that all five areas were equally important in their potential contribution to adverse outcomes. While the report was very important in highlighting the range of problems that were occurring at Morecambe Bay at the time, and that could have been occurring elsewhere in the country,  extrapolating from this that a 'cult of normal birth' exists, and that it is the sole and direct factor responsible for the death/morbidity of thousands of babies across the country, is scandalously bad journalism

3.       There is no evidence that there is an increase in incidences of perinatal asphyxia in the UK.

4.       There is no evidence that normal birth per se (any more than any other mode of birth)  is associated with baby deaths or damage.

5.       The evidence we do have, from reviews of good quality  randomised controlled trials, is that, if women have continuity of midwife led care, they are less likely to lose their babies (from early pregnancy to the early postnatal period, including birth), 24% less likely to have babies born prematurely, AND more likely to have a normal birth. WHO and many other responsible agencies around the world accept this evidence. 

6.       Indeed, WHO is currently working on a guideline to reduce unnecessary CS

7.       The current press coverage in the UK seriously risks damaging mothers and babies in the future if, as consequence, normal births fall and CS  or instrumental vaginal birth climb

8.       In the United States of America, which has one of the highest rates of intervention and one of the most expensive maternity systems in the world, maternal and infant mortality are one of the highest among the group of the worlds richest countries

9.       It is also unacceptable that our Secretary of State for Health, who is supposed to be concerned with reducing baby loss, has not challenged these deeply flawed claims, on the basis of the harm it may do to future mothers and their babies.

Given all this evidence, it is astonishing that the press are reporting the complete opposite. They should seriously consider if they are breaking their own press code of ethics, that states that they must adhere to the following:

Seek truth and report it

Minimise harm

Act independently

Be accountable and transparent

All of these ethical principles seem to have been violated in the elements of the recent reporting that link normal birth as a systemic problem, and as the (only) factor in adverse outcomes in mothers and babies.

It is clear that there are still some areas of poor practice which need to be addressed, but the outputs of recent quality assessments show that the majority of maternity care is excellent, including good collegiate relationships between midwives supporting women to have normal births, and obstetricians providing technical interventions where these are needed . Addressing poor quality care should not be at the cost of reducing this excellence.

Professor Soo Downe OBE

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

Is change is on the way? Place of birth

The National Maternity Review Team in England are working hard to gather evidence, opinion and visionary ideas for the future of maternity services. I have been invited to participate in two separate meetings, but am sadly unable to attend due to pre-booked holidays. I have lots to offer.

My action when participating in #MatExp #FlamingJune activity was to gather views of maternity services from willing individuals, by inviting them to write a post for my blog. Whilst it's now July, I am continuing with the action as contributions keep coming!   Please do get in touch if you want to have your say. I will send the link for the posts to the Team in good time.

So here is post 7. Natalie Meddings, mother, doula and active birth teacher, has a revelation. You can read about it below.

Natalie: 

Something astonishing has happened. Something that has caught me by surprise. A couple of weeks ago, while doing our usual how-are-you ? go-round in my  Active Birth Class, it hit me that more than half of the women in attendance were planning to have their babies at home. For the first time in the seven-year life of my yoga class, the MAJORITY were planning a homebirth.

It’s a microsample, it’s true. But 60% is 60%, especially when year in, year out, it’s been more like ten - one sole mother, keeping quiet in the corner in case her unconventional choice got challenged over tea.

Photo: Hannah 

Last week there was no self-silencing though. Neither was there any noticeable announcement. Quite the opposite, which is why I almost missed it.

As one after the other, they aired their plan to book a community midwife and see how things went, there was something ordinary about it - an almost casually-arrived-at agreement that this was common-sense, the most natural thing in the world to be in the most natural place in the world to give birth.

There were no faces made by those whose preference was hospital, or gasps of ‘you’re brave’.  Like many birthworkers, I’ve been spreading the female idea for years - why a safe and familiar space gives the female body full physiological chance of a straightforward labour . And suddenly here we were. Here we are, with that message starting to mean something.

To be fair, I think the ‘normal’ part of it had been helped by the group’s  avoidance of the word homebirth. Instead we’ve focussed on the all-options-open aspect to booking a community midwife - the in-built safety and control of having someone visit you in labour at home so that you can decide how you feel and what you want to do on the day.

Free of the homebirth heading, the idea was less loaded, less of a leap and as a result, an idea they could envisage.  Without a big, fixed plan, the women could more easily imagine themselves in such a situation, as well as the immersive benefits that setting offered biologically - deep privacy and quiet.

But there was something else behind this new turn too.  These women had heard lots of positive birth stories.

As recently even as three years ago, that wasn’t the case. A mother with a good birth story to share usually felt unable to. Pejoratively pigeonholed by the media as a ‘type’; silenced in NCT groups for fear she’d be crowing.  What could she to do but stay quiet?  Meaning that the stories pregnant women got to hear were overwhelmingly worrying ones - traumatic tales of long labours and apparently inevitable medical rescue.

But the word-of-mouth miracle that is social media has changed that. Instead of negative birth experiences installing fear and that fear going on to inform more negative experiences, the cycle is reversing. Women are now hearing lots of positive birth experiences, getting inspired and encouraged, and going on to have positive experiences too.

Support networks like my own tellmeagoodbirthstory.com and Milli Hill’s Positive Birth Movement  saw the super-powerful resource women could be for other women - and created an outlet for it.

Tellmeagoodbirthstory connects pregnant women with women who’ve had positive birth experiences by email; the now countless Positive Birth Groups around the country are a place where pregnant women can hear stories and share wisdom first hand. And from our kitchen tables, we keep the fire burning beneath it all with a busy and very buzzy presence on facebook and twitter.

‘I think about my birth every day of my life.’

‘At home, I understood what I had to do and the part I had to play – which was to let my body get on with it. It was much easier doing that at home, where I didn’t have to make any decisions to make or to think about anything else at all.’

 ‘In labour, there’s more rest than work – no one ever tells you that.’

These are the kind of comments women are hearing now – on their feeds, at groups, by connecting – so that it’s not so much the choosing to homebirth  that’s significant, but the increase in confidence.  Those women in my class being calm and in command of their experience.

Louise saying:  ‘I want to be able to listen to my body without distraction, to allow it do what it instinctively knows how to do.’   

Claire saying: ‘When I first found out I was pregnant a home birth was the last option on my mind. But having heard from other mums about labour, I’ve realised it’s being in the comfort of my own home, in my personal space that’s going to help me relax and let go.’

A few years ago, I questioned Mavis Kirkham, professor of midwifery at Sheffield Hallam University about the relationship between mothers and the maternity service.

‘The organisation of maternity services encourages women to take the attitude towards labour and birth that they would have towards a plane journey,’ she said.

‘Just as we buckle ourselves in and hope for the best on a flight, women are encouraged to do the same in labour. We feel there is nothing we can do to influence holding the plane up in the sky and so we switch off completely. Birth is a bit the same. Women can feel there is little they can do to affect the unfolding of the labour, that it is out of their hands, so they give responsibility to the pilot and trust they’ll get them to where they are going.’

But uninvolvement is on the wane. Women are starting to take charge, realising they can affect how their labour unfolds – and by listening to and learning from others, working out ways in which they can do that.

Self-assurance is growing from the ground up – and what the Maternity Services Review might consider are ways to foster that.

When tellmeagoodbirthstory first began, one hospital got in touch, interested in the difference a free mother-matching network might make to their birth outcomes. But they quickly grew hesitant when they realised they had no control over the information women were sharing. My local GP surgery was the same. When we asked to put up posters, the practice manager said: ‘how can we know what they are saying to each other?’

Though a degree of caution is understandable in a litigious society, paternalism like this misses a trick.  By trusting women, you engage women - they take part in and responsibility for their birth experience, and this in itself is a way to increase safety.

Mavis Kirham may have highlighted how disengaged the pregnant population has been in recent decades, but she is also the first to stress how easily reversible that is – through mother-to-mother education. Through community.

In particular, she has pointed to an estate in the north of England where a homebirth project was piloted. At first it was slow to take. But it only took a few mothers telling their neighbours what having a baby at home was like – and minds quickly opened. In no time, everyone was wanting one.

I think there’s a similar knock-on happening now. Slower to spread perhaps, but a chain of confidence nevertheless and this time the  community is country-wide.

Natalie Meddings

Natalie Meddings is mother to Constance, 13, Pearl, 11 and Walter 9 and lives in London. Natalie trained as a doula with Michel Odent and Liliana Lammers in 2003 and has been supporting women in birth ever since. Natalie became an Active Birth yoga teacher around the same time and have been running classes in Barnes, South-West London since 2008. Natalie set up 'Tell Me a Good Birth Story' a few years ago and ran it voluntarily with the help of hundreds of lovely, amazingly generous mums nationwide.

Thank you so much for this post Natalie! I refer lots of women and families to your site, and frequently mention you at conferences. You are an inspiration - Sheena 

You can follow Natalie on Twitter 

Guest post: an interview with Professor Soo Downe OBE

Added comment - March 2019

Professor Soo downe obe

During my career I have been inspired by, and aspired to be like, several midwives.

Professor Soo Downe is one of those, and I was incredibly fortunate to work closely with her during my role as a consultant midwife. Soo gave me confidence in my academic ability, and she fostered in me a sense of self worth. I remember hearing her giving a talk to several hundred midwives, and mentioning the work we did at East Lancashire Hospitals maternity service. I couldn't believe it. She really thought we were doing great things as a maternity unit, and it gave us a much needed confidence boost. Soo Downe is a transformational leader, and shares her knowledge and skills for the greater good, and not to receive accolade or to gain power. I was delighted that she 'agreed' to do this guest post, because I know that every nano second in her day (and night) is taken up with family and work. I hope you enjoy this small glimpse into Soo's amazing midwifery world.

Hi Soo, thanks for agreeing to chat to me here! Could you introduce yourself?

Hello my name is Soo Downe, I am a midwife and I qualified  in 1985. At the moment I’m working as Professor of  Midwifery studies at the University Central Lancashire in the Research in Childbirth and Health (ReaCH) team. Our main area of research is around the nature and consequences of normal childbirth.

When did you first become interested in becoming a midwife?

When I was at university in the late 1970’s, I had no intention of being a midwife at all. I was studying English literature and language, and beginning to wonder what to do with my life when all the years studying finally came to an end. In the middle of my degree studies, I found myself working at a maternity mission station in Bophuthatswana, which was a homeland in South Africa, at the time when the country was still suffering under apartheid. There was a long chain of events that led to me being there that is not worth going into, but the most important thing is I found myself watching women having babies quietly, peacefully with the loving support of the midwife nuns who were working there, with minimal resources, and, on reflection, no interventions that I can remember.

The labouring women were apparently completely unfazed by what was going on, and completely engaged in their labours. It came to me that, if we can get childbirth right, we can get the world right. It felt like a kind of road to Damascus experience, even though I’m not particularly religious. Having finished my 4 weeks in Africa, I came back and to finish my university studies, after which I worked for some months as a healthcare assistant at Guys Hospital in London. This was because I knew that midwifery was very unlikely to be the same in the UK as it was in the middle of a homeland in South Africa. Despite the differences, I still loved what I could see of the profession, so I applied to St Thomas’s Hospital in London to do nursing, because at that time I didn't realise that you don't have to be a nurse to the midwife. However, having been accepted on the nursing program, I found out that there were, at the time, two places in the country where you could become a midwife without having a nursing qualification. So I immediately applied to Derby City Hospital and that's where I undertook my midwifery training. It was not at the level of a degree or even a diploma, it was just 3 years of midwifery theory, practice, and skills development, and it was the most difficult thing I’ve done; far harder than my academic qualifications, because it mattered so much to get right.

Once I qualified I worked for about more years on the labour ward at Derby City Hospital. The labour ward had about 5000 births a year, so it was very busy, with a fairly high rate of interventions, including the early adoption of routine fetal monitoring for all women. This raised a whole series of questions for me that started to push me towards undertaking research, to find out what the implications were of what was happening. By the time I left Derby city Hospital in the year 2000 to move into academia, I had been working in a joint clinical and research midwifery post for several years.

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

Sadly, I am no longer working clinically, so my working day now is much less hands-on.  I work in a team of about 12 people, and they are divided into 2 separate but related groups,  one which I lead (the Research in Childbirth and Health group, ReaCH) and the other which is led by Prof Fiona Dykes (the Maternal and Infant Nurture and Nutrition group, MAINN). Much of our day is spent on the computer. This includes responding to hundreds of e-mails that come from all over the world from students and collaborators and colleagues, who are networking, writing papers, writing bids, and generally discussing questions of research and practice. More specific activities might involve writing a presentation for a national or international conference, meeting with one or two Ph.D. students to talk over the work they’re doing, talking to local midwives and doctors about the areas of research that might interest them, meeting with service users who are involved in some of our studies to discuss information leaflets, or how to disseminate research findings to a wide audience.

It might also involve the more frustrating bureaucracy that is growing all the time in higher education, just as it is in the health sector, including filling in large numbers of administration forms. I also attend a range of meetings, catch up with the work of team members,  review papers that have been submitted to journals or bids that other researchers have submitted to funding committees, or teach and supervise undergraduate or postgraduate students. Occasionally we get a bit of space to write an academic paper, or a bid, and the day includes great excitement when were awarded finally one of our bids (on average, for most academics, only about 1:10 bids are successful), or when one of our papers is finally accepted for publication, or when one of our students is awarded their qualification after all their hard work, or when the media contact us to find out about the results of one of our studies which might be significant in practice or policy for the future.

Fairly often I visit colleagues overseas, to give keynote lectures or to talk about future research projects. Indeed one of the really rewarding and reinforcing factors in my work life is a number of countries I visit where women and midwives and doctors and other stakeholders are saying the same thing:  we really need to get physiological birth right.

As you can see, it is extremely hard to sum up a typical day in this job!

The main focus of your work in promoting and supporting the normal birth agenda, can you tell us why this is so important to you?

What has always fascinated me is the sense that the process of childbirth is far more than just getting a baby out. It is something that links us back through all our ancestors, and into the future, and we are all (mother, father, baby) irrevocably marked by it. It is also one of the few experiences left in society which, when undertaken physiologically, is ultimately unpredictable and uncontrollable and, as a consequence, deeply emotional. It takes all those who experience it authentically to the very edge of their capacity to cope, and it says to them, you can do this – and if you can do this, you can do anything. Getting it right is therefore profoundly important for the wellbeing of families, and for future generations. While I have always believed this intuitively, recent exciting evidence from epigenetics seems to suggest that there is biological evidence for the impact of labour and birth on way genes might be expressed for the child, and for their adulthood, and then their own children in the future. So, for all these reasons, the normal birth agenda is really important to me.

There are some individuals and pressure groups in England that would like to abolish to the term ‘Normal Birth’. What are your thoughts on this?

I really dont understand why we can talk about 'normal child development' and 'normal adjustment to school' or whatever else, and not about normal childbirth. I am the mother of a profoundly disabled child, but I dont object when people talk about the normal development of their or any other child - I dont feel that that makes me or Jessica (my daughter) somehow less because she is (clearly!) not developing normally, and never will, and I certainly dont think I have the right to deny other parents the joy in the normal achievements of their own child. Why do we think we have the right to deny women who have normal births the right to delight in this? 

I do tend to use the word physiological when Im writing about normal birth in the professional sense, but women routinely use the work 'normal' in terms of pregnancy and birth, around the world - and, indeed, in my experience very few other countries see any problems with it. It is part of the  international definition of a midwife. I honestly think we should resist this populist pressure to redefine a fundamental female biological process as something 'other' that cannot be talked about. The problem is not with normal pregnancy and birth, but with the systems we have set up that render it almost extinct, so that women think that the traumatic things that happen to them in labour are 'normal' birth (indeed, I have seen a USA blog where a woman says her 'natural' birth was barbaric and horrific and then we find out half way down the blog that her labour was induced). Of course women who experience this feel they have failed, and are traumatised - but this is not normal birth, and it is not they who have failed, but us who have failed them - and we need to own up to this and change it. 

The less we talk about what normal birth is, the more it will vanish. We need to say, loudly and clearly: unsupported, traumatic birth with unconsented proceedures and non-present staff (in all senses of the word) is NOT normal birth. Normal birth as we have always meant and defined it is the kind of birth that most women, with the right support and skilled, compassionate care can achieve - and for those women for whom this is not possible or desired, then the optimal birth experience is necessary for them as well. Once again, it isnt either-or but both-and.

Sometimes 'normal' or 'natural birth' advocates are criticised for 'encouraging unreal expectations' for childbearing women. What do you think about that?

I think the best parallel here is with the breastfeeding debate. The reason women found it so hard to succeed in breastfeeding in previous generations was because of the insistence of maternity organisations on profoundly non-physiological ways of managing breastfeeding. This meant that we had a whole generation of women who had ‘failed’ in breastfeeding, and so who could not help their daughters to do so; indeed, I suspect that some of them felt that, if their daughter did try to breastfeed, this was an implicit critique of their own ‘failure’. We are now in this situation with physiological labour and birth. We have a generation of grandmothers, and of friends of newly pregnant women, who cannot contemplate their daughter/friend having a baby without, for example an epidural. This has happened because we have created the circumstances in which it is very hard for women to have their babies without such technological help.

What makes the expectations for physiological labour and birth unreal is not women's innate capacity by large (although of course for some women and babies there will always be a need to intervene). Unreal expectations only exist because we have setup maternity services to make them unreal. Where we create circumstances in which women are able to trust those around them to give them space to labour spontaneously the vast majority will succeed in labouring spontaneously and positively and even joyfully.

Photo: sarah brown

What are your plans for the future Soo?

It would be great to finish all the projects that I’ve started and that I haven't yet had a chance to sort out or write-up!. However I think this is probably never going to happen – indeed, just getting to the bottom of my e-mail inbox would be a massive achievement, but again I don't expect to achieve this before I retire in about 10 years time!. More seriously, the major piece of work I want to start with colleagues including Holly Kennedy from the USA and Hannah Dahlen from Australia is to look at how what happens during labour and birth influences the well-being of mothers, babies,  partners and families into the future, in terms of the epigenetic make-up of the neonate, long-term noncommunicable disease, and perhaps more importantly even, to find out what is about labour and birth that might help things to go right in the future for the baby and the family (see link). For example how,  is it that some women with a difficult personal or family obstetric or medical history, or difficult social history, still manage to have very positive empowering life affirming birth and others do not.  How many situations that are currently treated as  pathological, such as long gestation or long labour, are actually physiological for some women and babies in certain family contexts?. Ultimately, can we use this information to make the allegedly unreal expectations that women have at the moment real expectations, by changing the maternity services globally, so that it maximises the potential for the best possible outcomes to mothers and babies in the future?

And lastly….what motivates you to continue to champion the cause?

All the factors above, I think! 

Aaaaa Thank you Soo, for this incredibly insightful interview. So many childbirth workers (and childbearing women) are grateful for your hard work, passion and dedication.

You can contact Soo at:

SDowne@uclan.ac.uk

Link to paper The EPIIC hypothesis: intrapartum effects on the neonatal epigenome and consequent health outcomes

A Normal Birth week! With Mary Ross-Davie

3rd-7th June 2013

Well, what a week! It was busy, busy, but it was like being in midwives’ heaven. It's one thing being able to listen to inspirational individuals talking about a topic you are passionate about, and quite another being surrounded by like minded ‘maternity’ people for a whole week! Wow.

And Mary Ross-Davie and I were together for that week, at three different Normal Birth events!  So, whilst now missing each other’s company, we decided to write a joint post on our reflections of each event, and to share the pleasure with you all. Hope you find it useful…

The first event was the Royal Society of Medicine, Maternal and Infant Health Normal birth Symposium, in London on the 3rd June 2013.

Congratulations must to go to RCM President Prof Lesley Page, on the organisation of such a stimulating and successful study day!

With more than 300 delegates, the whole day felt alive with passion, inspiration and hope for the future…and it was wonderful to see vibrant, enthusiastic student midwives such as Oli Armshaw, Hana Ruth Abel and Natalie Buschman mingling with midwifery greats such as Caroline Flint and Nicky Leap. These students are our future (and we have so much faith in them!!), and they are hungrily receiving the baton.

The programme was a great mix of speakers sharing research findings, experience from clinical practice and exploring and celebrating normal birth. 

Mary Ross-Davie presented her ground breaking PhD research findings. Now I believe Mary’s work has the potential to change midwifery services, and if used, can add strength to influencing staffing levels. Mary's study, SMILI (Supportive Midwifery in Labour Instrument) looked into the nature of midwifery support in labour. The results are powerful yet not surprising, and include evidence that having enough midwives makes a difference to normal birth rates and satisfaction of childbearing women.  Mary's thesis can be found here.

Mary said:

When I started my PhD studentship in 2009 I hadn’t imagined that at the end of it the President of the RCM would be inviting me to speak about my study at a Normal Birth symposium alongside Professor Nicky Leap, Professor Cecily Begley and Professor Lisa Kane Low.

Nicky Leap has written widely about the power of midwives’ approaches to pain in shaping women’s experiences: where we talk about ‘pain relief’ rather than talking positively about the pain of labour we can undermine women’s confidence in their own abilities. Nicky encourages midwives to use the phrase ‘Working with Pain’, and pointed delegates to an NCT resource http://www.nct.org.uk/birth/working-pain-labour) . Nicky’s most recent research has reaffirmed the power of listening to women’s words and stories to learn how to provide better care. It also reminded me of the great impact that film can have in getting women’s voices heard. Nicky and the team of researchers from Kings College London, used videos of women talking about their experiences of care in a learning package for staff.  Nicky showed a short extract of one of the films and the message from the women was clear: what midwives say and do and how we do it has a huge impact.   You can see what Nicky has to say about workshops for maternity workers when working with women who request epidural anaesthesia in labour.

Consultant Obstetrician Amali Lokugamage never fails to silence an audience. Her articulate, sure, yet gentle style is immediately capturing. And Amali is a unique speaker in that she provides delegates with a detailed and understandable insight into the world of medical practitioners. Maternity services frequently fail women and families when collaboration between health professionals is absent, and so often we hear of tensions between midwives and obstetricians. If health professionals understand each other's back stories and perspectives, and the underlying reasoning behind those perspectives, then there is potential for positive relationships to develop and flourish. After having a home birth, Amali is able to draw on both that experience, and her medical training, to help us to consider the best way forward. Amali's book, The Heart in the Womb, is a must read. Really.

To be honest, the third stage of labour has never really captured my imagination as much as other parts of the childbirth journey, but Cecily Begley’s talk, along with seeing Dr David Hutchon at the Mama Conference  earlier this year, has changed that.  Her research into Third Stage Management has included a Cochrane systematic review and the ‘MEET’ study which explored Irish and New Zealand midwives’ expertise in expectant management of third stage.  There is a growing body of work about the impact of early cord clamping and the importance of taking time to get that first hour after the baby is born right. Cecily powerfully argued that physiological management of third stage should be a basic midwifery competency.

 Kenny Finlayson from UCLan reported on the feasibility issues of The SHIP Trial (Self Hypnosis for Intrapartum Pain)  which is due to be reported on at the end of 2013. We look forward to that.

Kathryn Gutteridge shared some of her philosophy of birth and how she has worked to make this a reality at the new birth centre where she is consultant midwife in Birmingham.  She spoke about getting the physical and emotional environment right for women, for them to have the most positive birth experience possible: she and staff at the unit approach the labour and birth as a unique day in a woman’s life much like a wedding day.  Imagine if we treated all the families we look after as if we were their wedding planners for the day…

Mary said:

I loved presenting my research alongside these and other great speakers on the day.  As a new researcher presenting my findings I have found it so helpful and encouraging to get instant feedback from people after my presentations through Twitter.  Research can be quite an arduous and lonely process, peoples’ responses raise my spirits and encourage me to keep going. What people pick out to tweet shows me what messages really come across strongly.  You can find comments (Tweets) about Mary’s talk, amongst the others, here! 

The next event was UCLan's Normal Birth conference, Grange over Sands 5th-7th June, 2013

        ‘Getting it right first time: normal birth and the individual, family, and society’

This famous international conference, organised by Professor Soo Downe and her team from UCLan, always attracts researchers, obstetricians, doulas and midwives from all over the world. This year delegates travelled from many countries including New York,  Netherlands, Germany, Brazil, Australia and Italy. The conference has a unique atmosphere – a beautiful location where the sun always seems to shine, with a relaxed feel that belies the serious research that is presented.

Jenni Cole gave a keynote address on day one, which focused on Anti-microbial resistance (AMR) and the overuse of antibiotics in neonatal care. It is estimated that between 90 and 99% of antibiotics administered to newborns are unnecessary, costing the NHS as much as £150 million per annum. In August 2012, NICE published Clinical Guideline 149: setting out clear guidance on when antibiotics should be administered and when they can be withheld. Whilst in theory compliance with the guideline should have reduced antibiotic use, there is evidence that doctors and other health care workers are reluctant to change embedded behaviour patterns. Jenni is looking for English Trusts to participate in research into the issue, and wants to be contacted by email here: JenniferC@rusi.org

This year some of the keynote speakers highlighted initiatives aimed at improving normal birth rates in the USA, Brazil and the Sudan.  One of the key shared threads between these talks was the need for strong collaboration between midwives and obstetricians, to strengthen normal birth.  Dr Nasr Adalla from Sudan, where less than 50% of women give birth with a skilled attendant, spoke about his belief in the right of women to choose a  home birth with skilled support. Keynote speaker Maria do Carmo Leal spoke about the challenges faced in Brazil, with only 15% of births assisted by a nurse or midwife and a very high caesarean section rate (overall 45%, though in Rio the rate is 80-90%). A new programme of work there led by obstetricians, midwives and politicians, called ‘Rede Cocogna’ is working to change this and has led to the opening of 42 new birth centres.

So many fascinating insights have come out of the NPEU Birthplace study. Professor Christine McCourt shared some of the qualitative results in her talk. The study confirmed how far we have come from the simplistic midwife v doctor dichotomy in relation to normal birth, highlighting more tensions between midwives working in alongside midwife led units and their midwifery colleagues in consultant led units than between midwives and obstetricians.  It made me wonder what we can do to try to lessen these damaging divisions within our profession (answers on a Tweet to me please! ‘@maryrossdavie’).

Miranda Dodwell from Birthchoice UK has been working with Prof Jane Sandall’s team at Kings College London. This work has highlighted the huge variations in normal birth rates between NHS trusts in England:  ranging from 30-50%.  A number of factors appear to make a normal birth less likely for women including being over 30 years old and from the least deprived quintiles. Miranda undertook some really interesting subgroup analysis of the data and found that ‘low risk’ multips had a 75% normal birth rate compared to 15% in ‘high risk’ primiparous women.

Another fascinating source of comparative data is the Europeristat programme of work, presented by Alison MacFarlane, this compares key information about birth processes and outcomes between European countries.  Again this raises so many questions for me: why are our stillbirth and neonatal death rates in the UK so much higher than Scandanavian countries?  Why did the caesarean section rate in Scotland rise by 3% from 2004-2010, compared to a rise of 1.6% in England? Why are normal birth rates so variable: 42% in Scotland in 2010 compared to 47.2% in England and 50.2% in Finland?

The great thing about this conference (apart from the brilliant people to talk to over the wonderful food) is the sense that you get of a very lively questioning research community that is searching for the answers to how we can make positive normal birth a reality for more women.  We didn’t get to see other top speakers: Professor Billie Hunter talking about her work investigating resilience in midwifery and Mary Sheridan on her work exploring vaginal breech.

The next Normal Birth conference is being planned to be in Rio, Brazil in 2014. Now THAT should be one not to miss!

To read more about the conference, see the Twitter feed here, and Consultant Midwife Dr Tracey Cooper has written extensive notes and made them available here Normal Labour and Birth Conf 2013

Believe in Birth Study Day, Montrose, 7th June 2013

Last but not least, Mary and I (and Kathryn Gutteridge too!) were honoured to be invited to the famous Montrose Birth Centre, in Scotland, to speak at their study day ‘Believe in Birth’. When we arrived the sun was still shinning outside and in, that is there was an abundance of smiles and warm welcomes from ALL the staff who work there. Delegates were offered a visit to the Birth Centre in the morning before inspirational leader Phyllis Winters opened the day with enthusiasm and positivity.

There wasn’t a murmur in the room when consultant midwife Kathryn Gutteridge sensitively talked of the effects of child abuse on childbearing women. Kathryn’s words shook us all, and it was clear from the faces of delegates that there was recognition of suffering.

One of the wonderful Birth Centre midwives, Iona Duckett, spoke passionately about her work, building on Mary Ross Davy’s SMILI study, using the ‘TEA’ tool, for emotional assessment in labour. Another special midwife, Jane Wanless, told the story of her midwifery journey. She made us laugh and cry.

Read more about this not to be missed study day here on Twitter!

At the end of the week we felt totally invigorated and enthused to continue with drive to support and protect midwifery and obstetric practice that respects and upholds physiological childbirth. The practitioners who were fortunate to be part of these three amazing events will hopefully be uplifted too, and feel energised to take messages back to their areas of work.

We now need to follow up the suggestion from the RCM's Campaign for Normal Birth steering group (of which we are both members) for a Normal Birth week every year, and also to make events more accessible for maternity workers at all levels.

What are your thoughts on this? Please leave your comments below!

Meet Geraldine Butcher: a wee wonder!

In the theme of 'Nursing and Midwifery History', and after the great response to my last post about Miss Fenton, I thought it would be great to interview a couple of 'midwifery greats' and to publish their stories right here, on Five Girls.  Here is the first midwife, the wonderful Geraldine Butcher! 

I first met Geraldine at the MAMA Conference last year in Troon, Scotland, and immediately felt a connection with her. Her smiling face beamed across the dinning table, and she made me feel welcome in her country. 

Geraldine began nurse training in 1978 and  thought she wanted to work in surgery or in coronary care…until she went to the maternity unit during the second year of her training. At that time they were chronically short of midwives and she was often caring for women until the second stage of labour (fills her with horror now but in her naivety she felt trusted, and loved it). Due to this experience, Geraldine decided to become a midwife. However…..that same year she had become instantly broody, which resulted in her sitting her nursing finals 36 weeks pregnant!

When Geraldine's baby son was 7 months old she worked as a staff nurse mainly doing postnatal care of women and babies (that was quite common in those days). When her second child was 3 yrs old she began her midwifery training in the same hospital; completing in November 1987.

So, Geraldine agreed to answer some of my questions, so you can get to know her a bit better too!

Hi Geraldine, thanks for agreeing to be interviewed! Could you describe briefly what your role is at the moment?

Hi Sheena, I am Consultant Midwife in NHS Ayrshire and Arran with a special interest in Normality

How long have you been working in this position, and what do you like most about it?

I have worked in Practice Development since 1996 (although continuously in clinical practice) and was fortunate to gain my Consultant Midwife post in 2007. At this time posts in all but the smallest health boards were created to implement the Midwife Led aspects of the Framework for Maternity Services. The work was called the Keeping Childbirth Natural and Dynamic Programme and I was proud to be the local champion.

Being a Consultant Midwife allows me to keep in touch with clinical practice, research and audit, professional development and education all within a leadership framework. All of these things are very important to me and I would hate to lose any aspect. I can change local practice (although that brings its own challenges on occasions) and also influence national strategy and developments.

 You have been a midwife for more than 25 years, do you feel maternity services have changed in that time?

I have been a midwife more than 25 years but have worked in maternity services for 30 years. I loved my maternity placement as a student nurse (everyone had to be dual trained then) and got lots of responsibility during my placement. I completed my nurse training sitting my finals at 36 weeks gestation as my maternity secondment had left me so broody. During my second pregnancy I moved back home to Ayrshire. Minutes after giving birth my husband jokingly asked if there were any jobs (I hope he was anyway!) Turned out they were so short of midwives they employed a few staff nurses. When my son was 7 months old I started working in maternity care. Again I did everything but listen to fetal hearts in the ward areas but was not utilized in labour ward, which at least was something. In those days accountability and risking registrations wasn’t really a discussion topic!

In 1985 I started my midwifery training and was extremely proud when I qualified in 1987. There was still a lot of medicalisation of normal birth at that time, and it is hard to change a system that has been in place for nearly 20 yrs. Women declining any antenatal screening was rare, even though the information they got was little or none. Most women had a late antenatal vaginal examination. Induction rates were higher than they are now with most women being induced by 41 weeks gestation. Interestingly though caesarean section rates were much lower…no epidurals, no FBS, VBAC was the norm and I don’t remember anyone expressing a profound fear of birth or requesting caesarean section. Was that because women knew there was little point in not going with what staff recommended, or was it because they were more philosophical about birth? Women getting out of bed during labour never mind birth was virtually unheard of. Episiotomy rates which had been almost 100% in 1980 were now lower…but don’t you dare have a perineal tear!...intact or episiotomy or you are in trouble. Shaves and enemas were on their way out but ARM on admission and IV infusions remained very common place. All women with very few exceptions had continuous monitoring in labour. Postnatal stay for normal birth was 3 days and midwives visited every day until day 10.

 However!....from 1988 we gradually started inching our way back into being lead professional for healthy women having uncomplicated pregnancies…our blue spot ladies didn’t see a consultant at all antenatally and in labour ward our first midwifery cases started…… 

What improvements do you think maternity services need to make, if any?

 We need to listen to women and have stronger focus generally that birth is a psychological emotional and social process, not just a physical one. With limited resources we can't be all things to all people, but care and compassion cost nothing. Women's perspective of risk is not always the same as ours and we need to stop shroud waving.

 In order to give sensitive, individualised care however we really need good continuity of carer (and if that’s not possible good continuity of philosophy). We need the right number of staff to care for them and that is not being achieved in many areas now. Stressed staff caring for too many women will make mistakes and communication will fail.

If we can do the above then everything else should fall into place (rose tinted glasses maybe but need to hope)

As a midwifery leader, how do like to influence future generations of midwives?

 I think I do my wee bit locally by speaking to student midwives but I think social media is a great way to give snippets of good quality information, or provide constructive comment and suggestions with potential to reach many more students or those thinking about midwifery as a career. It is amazing the number of young people on twitter and actively using it and tweetchat. Perceptions of hierarchy disappear when you are behind a computer screen so they can challenge safely..and they do. MAMA conference recently had a large number of student attending and this was very encouraging…they are committed to change and they are the future of maternity care.  

I have also published and presented work, which hopefully helps!

Well, thank you SO much Geraldine, for giving us an insight into your early career, your philosophy of maternity care, and your role as a Consultant Midwife! Keep up the great work you are doing; you are making a difference. 

If you want to follow Geraldine (she's a avid 'Tweeter') on Twitter, she can be found at @gbutcher17

Promoting normal birth on the Throne of Words

When I was invited to Southlands High School in Chorley to talk about my book Catching Babies, I wasn't sure what to expect. The email inviting me specified that the health and social care students in year 10 would ask me questions in relation to my career as a midwife. This was quite a different process to what I am used to; I usually give a short talk about my career and my book, and the questions follow. But this group of 40 14 years olds hadn't read my book, but were as their teacher later told me 'interested in healthcare professions'.

So I arrived at the school at 8.30 ready for the 9 o'clock bell and first session of the morning. I was warmly welcomed by one of the subject teachers, Jill. Jill explained that the students had prepared questions for me, and she thought the questions were bob on.

As I watched the girls (no boys in this group!) slope in, in couldn't help propelling their teachers into the realms of the most esteemed group of professional workers; coping with this adolescent group on a daily basis. Respect.

But I was impressed with their questions. 'What do you think about home birth?' was the first enquiry. 'What was your  scariest moment?' 'When I watch "One Born Every Minute" women say they can't go on, what do you do in those situations?'

So. I was able to talk to these impressionable young women about birth. Birth as a right of passage, birth as a normal physiological process- a social occurrence not a medical procedure. I realised that this was a wonderful opportunity, and I was in a very privileged position.

I wonder what they thought?

Brighton: the English version

My work as a midwife has brought us once more to the lovely English seaside resort of Brighton. I was here in September last year to give a talk to the midwifery students at Brighton University, and from that was invited to do a workshop on promoting normal birth for the maternity services at Brighton and Sussex University Hospitals.

Paul and I have happy memories of another Brighton, the one on the East Coast of Australia. It was there that we reunited with our lovely son Tom and his very lovely girlfriend Claire when we visited the Antipodes last September. Tom and Claire were working there and we were thrilled to see them looking so well and happy!

So this Brighton gave us the opportunity to reunite with another special person. Laura is our beautiful fun loving (and nut cracker thigh-ed!) friend, and she lives here with her outdoor active handsome boyfriend, Gerome. I first met Laura when she was a teenager and she was at the same dance school as Anna. Not only that, Laura was very talented (as Anna was) and we would watch her grace and strength with awe as she worked her magic through movement. Laura works in the dance world still, and does amazing things to engage potentially talented youngsters with the arts, through dance. We were also lucky enough to have Laura as our babysitter, and she was just as talented with our young ones. Laura proudly showed us the best places to go in Brighton, and as we sipped pink tinged wine, ate tapas, and listened to live music we chatted for hours about many things. Great stuff.

So now we make our way to Cathy and Rob’s White Wickets and we say goodbye to Brighton. As we pass through the East Sussex countryside through patchwork fields brightened by the yellow rapeseed blossom contrasting yet complementing the cornflower blue skies, we can’t help thinking about Simon and Caroline at Five. Five is a wonderful contemporary family run hotel that serves guests with a scrumptious organic breakfast at the start of the day. We had a comfortable room with a sea view, and Caroline kindly helped us to store and access our push bikes….

See you soon Brighton!