The Pursuit of Normal Birth at Any Cost: Where Did it Come From and Where Has it Taken Us?

First published in Midwifery Matters summer 2025

By Gillian Meldrum

Origins of the phrase and its meaning

I believe this dramatic and hurtful (to me) phrase was first introduced in the 2015 report of the Morecambe Bay Investigation by Dr Bill Kirkup, when he wrote, “There was a growing move amongst midwives to pursue normal childbirth ‘at any cost’” (p 6 para 4).

We all know it was not meant literally – if that was the case there would be no caesarean births at all and midwives would be prepared to pay the price (‘any cost’) of maternal death or stillbirth in order to achieve ‘normal birth’. It just cannot be true, but it is a most unfortunate and careless exaggeration which has powered the idea that some midwives just don’t care enough about the safety of the families they care for, and supporting women to achieve physiological birth can in itself be dangerous. Even though some midwives might have room for development in their confidence, competence and skills, I have never known any who are not fully and absolutely committed to safety in childbirth.

It feels like a fundamental undermining of all midwives, and is difficult to square with the NMC midwifery standards which state that the role and scope of the midwife is to “optimise normal physiological processes”.

What the Kirkup report actually said

Let’s take a look at what was actually said. Firstly, it is important to note that Kirkup included it as one item in a list of failures in a “seriously dysfunctional service” with clinical incompetence, deficient skills and knowledge, extremely poor working relationships, failures of risk assessment, repeated failure to investigate adverse events and learn lessons – which together “comprised a lethal mix” that led to unnecessary deaths of mothers and babies.

The actual phrase is directly attributed (p13) to senior midwife Lindsey Biggs (subsequently sacked and then removed from the NMC Register).

It was further noted that, “Midwifery care in the unit became strongly influenced by a small number of dominant individuals whose overzealous pursuit of the natural childbirth approach led at times to inappropriate and unsafe care.”

So, in a seriously dysfunctional unit, a few dominant and bullying senior midwives influenced practice, leading to unsafe care. But their malign influence clearly extended far beyond the pursuit of ‘normal birth’, leading to appropriate interventions sometimes being withheld. It also included tolerance for many other kinds of clinical incompetence – for example, the tragic case of James Titcombe’s son Joshua who died as a result of infection that was missed for almost 24 hours, despite clear signs, with all midwives involved claiming they didn’t know that hypothermia in a neonate could signify infection (p19 para 1.22). Forget about pursuit of normal birth – an elective caesarean birth in that unit would have felt unsafe to me.

Kirkup’s investigation concluded with 44 recommendations, none of which related to ‘the pursuit of normal birth’. This is most unexpected, given its inclusion as a factor in the ‘lethal mix’. If this was indeed a serious concern, why was no thought given to how to address it? And yet, disappointingly, the inappropriate ‘pursuit of normal birth’ was the main message widely reported by the media.

How the narrative spread

A Guardian article presented ‘The cult of natural childbirth has gone too far’ as the ‘key finding’ of the report. The Daily Mail described a “dangerous obsession with natural childbirth” (despite there being no use of the words ‘cult’ or ‘obsession’ in the report).

It is understandable that the mainstream press seeks dramatic, simplistic and potentially misleading headlines to attract readers’ attention – but the result was that the more objective findings about dysfunctional organisation and incompetent care were less widely discussed. I have no doubt that these failings had an impact on many different women and babies, including those who achieved the birth they wanted, whether physiological or caesarean birth, as well as those who experienced tragic avoidable adverse outcomes.

Subsequently, the phrase was repeated during the parliamentary inquiry Safety in maternity services in England chaired by Jeremy Hunt MP in 2020-21.

Laura Trott MP (who as Chief Secretary to the Treasury failed to understand national debt was rising) asked Dr Kirkup about his finding ‘there is a growing move among midwives to pursue normal childbirth at any cost’ (Q43) and asked him what could be done to ‘stamp this out?’

Dr Kirkup (whom she had misquoted, as his finding referred specifically to Morecambe Bay, in the past tense) replied that he had no evidence as to “whether that is a general trend that is of concern,” and continued, “We have to be careful about extrapolating from … units that have got into end stage failure, where it has certainly been a factor. … That is too much of an oversimplification, we can have lots of appropriate normal births, and we can also have a safe service.”

Donna Ockenden, chair of the review of Shrewsbury & Telford Maternity Services, also gave evidence. Her interim report, had presented lower than average caesarean birth rates and reflected that women “appeared to have little or no freedom to express a preference for caesarean section or exercise any choice on their mode of delivery”. I can find no specific mention of ‘normal birth’ in the report, but despite this, the Guardian claimed the report had “deplored the NHS trust’s culture of ‘normal birth at almost any cost’”. Once the narrative had started, it couldn’t stop!

Donna Ockenden told the inquiry, “We have spoken to hundreds of women who said to us that they felt pressured to have a normal birth. We will be writing more about it in our next report.” (Q151)

(But she didn’t write about it! There was no further analysis of this issue when the final Ockenden Report was published in 2022 and no related recommendations other than general ones around informed consent. If this was indeed a major contributor to lack of safety in maternity care at Shrewsbury & Telford, why were no essential actions recommended to specifically address this problem?)

Where is the evidence?

The inquiry held a roundtable discussion with midwives and reported, “the majority of attendees had not experienced a culture that promoted ‘normal birth’ at the expense of safety.” Jacqueline Dunkley-Bent, Chief Midwifery Officer, said (Q59) “It is not in a midwife’s DNA to support normal birth at any cost.”

Despite this, the inquiry concluded that the most important focus for safe and personalised care should be to ensure that no woman “faces pressure to have an unassisted vaginal birth… Furthermore, those organisations need to work hard to stamp out the damaging ideological focus on ‘normality at any costs’ which caused such huge loss and suffering.”

If you read the transcript it appears that the committee held this opinion from the outset and repeatedly invited witnesses to confirm this viewpoint. No attempt was made to scrutinise evidence that such an ideology really existed or to reflect on how it might best be addressed. No academic midwives were called to provide evidence, and the only parent witnesses were those who had experienced a baby loss. There was no consideration given to possible experiences of pressure to have unwanted and unconsented interventions.

The next significant report came with the East Kent Investigation by Dr Kirkup in 2022.

Although he avoided a repeat of the phrase ‘pursuit of normal birth at any cost’, he did continue with the same narrative by saying there was an expectation that [‘normal birth’] was an ideal that staff and women should strive to achieve which was potentially harmful as it sometimes resulted in failure to intervene – specifically, when such an ideal is promoted ‘unselectively’. (I would agree with that – any view applied ‘unselectively’ is likely to be unsafe.)

In section Flawed teamworking – pulling in different directions he reported dysfunctional team working. He clearly lays the blame on midwives, rather than doctors, for a polarisation which “cannot help but put them in conflict with obstetricians,” as they may be encouraged “to see themselves as being ‘there for women’, defending them from the ‘medicalisation’ of maternity care” and holding an “inflexible interpretation of a wider maternity debate, positioning midwives as the defenders of women against intervention and obstetricians as the inflictors of over-medicalised models of care.” (Does this sound to anybody else like really oldfashioned language dating back to the 1980s?) It is not clear who or what has ‘encouraged’ midwives thus (could it be the NMC?), and he doesn’t seem to consider that obstetricians have any possible contribution to make to promote a safer culture of multidisciplinary trust and mutual respect, to improve their image of ‘inflictors’ of unnecessary intervention. Nor does he acknowledge the medical hierarchy and power imbalance between (and within) the two professional groups, which can also contribute to dysfunctional team working.

 He expects (as we all do) that there should be effective team working between doctors and midwives, sharing a common purpose – without making clear what that common purpose would be. With reference to VBAC he says, “Such decisions need to be taken carefully, free from inherent prejudice about the ‘best’ method of delivery.”

Midwives or obstetricians should not be making decisions, however careful and unprejudiced, as only the birthing woman can decide what is ‘best’ for her – and this applies to decisions about requesting as well as declining interventions.
Our common purpose might be to offer unbiased, evidence-based and personally relevant information, based on a comprehensive assessment, to help women make their own decisions, and then do all we can to help them achieve the birth they want by creating as safe and trusting an environment as possible, however the pregnancy and birth progress.

The East Kent investigation reported that for 69% of baby deaths, the outcome could have been different if care had followed
nationally recognised standards – i.e. staff were not following national standards. This seems a more objective analysis of the causes of problems than the much less tangible ‘prejudices’ of (I guess midwifery) staff.

Reclaiming support for physiological birth as acceptable

So it is nothing new to say that physiological birth is inherently dangerous and only safe in retrospect. But this recent concern, ‘the pursuit of normal birth at any cost’, has taken it to a new level. Now, anybody who supports, encourages and protects physiological birth might be accused of having an ‘ideology’ which ‘must be stamped out’.
An ideology which entitles staff to pressurise women (and colleagues) to do whatever they think is right, might indeed be an ideology which needs to be stamped out – or, to put it more gently, which should be questioned and transformed.

But it needs to be said out loud that physiological birth is the safest kind of birth for the majority of women and babies, desired by the majority of women, and therefore should be encouraged and supported – and an ideology which recognises these facts is not harmful. Equally the needs of women who choose caesarean birth should be met and women aiming for physiological birth should be offered comprehensive and competent assessment throughout the perinatal period, and timely and appropriate interventions when complications arise. This ‘ideology’ has been adopted by WHO, FIGO, ICM, ACOG and until not so long ago the RCOG and RCM.

A more positive way forward

In order to support women to achieve physiological birth, when this is what they choose, maternity staff must have knowledge and understanding of how to positively and pro-actively support physiological birth and a commitment to provide that support. This includes facilitating sometimes difficult decisions to get the right balance between ‘too little, too late and too much, too soon’, which requires sensitive communication skills and a sound knowledge base in order to convey reliable information on the risks and benefits of different options. There is no doubt room for improvement with these skills for some midwives, but I think the narrative of ‘pursuit of normal birth at any cost’ has made midwives more reluctant to encourage and support physiological processes, even when women have told them that is what they want. Equally it can make families more fearful that they cannot trust staff will be dedicated to their safety, and they might not be offered the interventions they need, leading to increased stress and anxiety and consequently increased adverse birth outcomes.

Let’s have a better dialogue where we consider how we can improve maternity services for all families and staff without demonising those who advocate for better support for physiological birth. This involves listening to different views, acknowledging that birthing women and staff can be more or less risk averse regarding both interventions or non-intervention. Most importantly, let’s not equate unsafe, incompetent and substandard care resulting in failure to implement necessary interventions with support for physiological birth and let us challenge the use of the phrase ‘pursuit of normal birth at any
cost’ whenever we hear it.