It’s official – the concept of ‘pursuit of normal birth at any cost’ will be considered in the national maternity and neonatal investigation. Its scope includes ‘understanding the impact of specific professional beliefs and approaches … the extent to which a ‘normal birth ideology’ exists in maternity services, the normalisation of pain, and the extent to which avoidable serious harms and deaths are normalised’
Let’s hope Baroness Amos and her team interpret these as genuine questions, which they approach with an open minnd. Before understanding if, and to what extent, such an ideology exists, and may be associated with avoidable serious harm and deaths – it is essential to be really clear about what ‘normal birth ideology’ might mean.
The term ‘ideology’ (ie based on beliefs rather than facts, sometimes held inflexibly and associated with impractical idealism) can be just a pejorative word for principles in which you happen not to believe – so its use does unfortunately imply a biased starting point. (More neutral alternatives might be ‘normal birth philosophy’, ‘social (vs medical) model of birth’, ‘salutogenesis’ or ‘advocacy for physiological birth. Let’s be thankful they have not used the phrase cult of natural birth.)
An ’ideology of normal birth’ would start with a belief that physiological birth (without medication to induce, augment or alleviate the pain of labour, or surgical/instrumental intervention) is the ideal way to give birth.
The most extreme version of this would be a belief that physiological birth is the ideal for everybody giving birth, and that no midwifery support and assessment leading to possible medical intervention is desirable. Some people may believe that death and suffering are a just punishment for sin. In Victorian times some people argued that it was immoral to use analgesia, because God had punished Eve’s original sin by imposing pain in childbirth on all women, and so this punishment should be endured. Others today might disagree with an adequately publicly funded health service and say that poor people don’t deserve to access maternity care funded by taxing wealthier hardworking people (see recent USAID cuts). Some might believe that all you have to do is think positive, feel the love, make healthy choices and ‘all will be well’.
No health professionals hold such an absolute aversion to intervention in childbirth, and all would agree that physiological birth is not ideal for everybody, including those who would certainly or most likely die or suffer harm without intervention, and those who choose not to experience physiological birth. Despite this, it has been claimed repeatedly since 2015 that some maternity staff ‘pursue normal birth at any cost’. We might be exhausted, stressed, traumatised, desensitised and ultimately uncompassionate – but not to that extent.
A more common ideology might be that physiological birth is the ideal for the majority of people giving birth because it results in better short- and long-term physical and mental health outcomes, costs the NHS less and gives midwives a sense of purpose and job-satisfaction. Health professionals decide who can safely give birth physiologically, and encourage, pressurise or coerce those people to have that kind of birth. This might include giving one-sided biased information about the benefits of physiological birth and the risks of medical interventions, not really listening to birthing people’s concerns, discouraging or denying them access to analgesia or caesarean birth on request and sometimes having a casual approach to monitoring, assessment and escalation, perhaps because they have an undue faith in their ability to judge and predict outcomes and a tendency to believe that ‘all will be well’.
These kinds of beliefs and associated practice result in a lack of safety and adverse outcomes.
If some staff feel they can decide what is best for birthing people, fail to offer clear and unbiased information, pressurise or coerce them into doing what they think is best, don’t listen to them, deny their requests and just hope ‘all will be well’ – this is not exclusively done in the service of promoting ‘physiological’ birth.
The exact same biases exist when promoting another professional belief system – what might be called the ‘medical model of birth’ or ‘intervene just in case’ ideology. Its proponents might believe that routine interventions in birth (and giving birth in obstetric units) benefit the majority of people, make decisions on their behalf based on this belief, encourage, pressurise or coerce them to accept interventions, offer limited and biased information, fail to listen to their concerns, deny them access to out-of-hospital births or ‘out-of-guideline’ care and have very little knowledge or understanding of the processes of physiological birth and their potential role in supporting it. This can be accompanied by a lack of understanding of the risks of ‘medical model’ birth, consequent inadequate monitoring and a belief that ‘all will be well’, particularly as interventions become more common, normalised and their safety is taken for granted.
This so-called ‘medical model’ of birth also sometimes determines practice and is associated with adverse outcomes and harms.
These issues of not being listened to, having their concerns dismissed and their needs unmet, have been reported by families in all the recent maternity scandals – and have sometimes been attributed to ‘normal birth ideology’ rather than to non-personalised, disrespectful, impersonal, coercive, ill-informed and under resourced care in general. This is not an ideology, it is a pattern of behaviours that reflects a maternity culture with a patriarchal and authoritarian foundation, which sometimes disrespects and fails both those who want or need intervention in birth and those who do not.
Maternity staff are all positioned somewhere along a continuum of being more or less risk averse to the potential harms of either medical intervention or of physiological birth – based on their previous personal and professional experience, the culture they work in, their personal values and personality and their understanding of the factual evidence. Some are more afraid of ‘too little, too late’ and others worry more about ‘too much, too soon’. The same applies to birthing families, journalists and the general public.
Equally everybody is more or less committed to the idea of birthing people making their own individual decisions about their care, based on evidence-based information shared with them, and their own values and choices – rather than expert professionals making decisions on their behalf and potentially dismissing or devaluing their views and preferences.
So what would a more acceptable ‘ideology’ look like?
Safety would be the first focus, including physical, emotional and social outcomes for the whole family, in the short-term, for future pregnancies and in later life. This requires an understanding of the possible benefits and risks of all interventions and the positive impact of relationship-based care on safety, the evidence for which is not always well known or understood in the current climate dominated by the ‘medical model’. It also requires staff to take note of birthing people’s experiences and reports when assessing wellbeing or progress, and not assume that professional judgements are always more reliable than the birthing person’s.
The second focus, linked to the first, would be the autonomy and agency of birthing people – so that decisions about care are determined by their choice and preferences, making health professionals’ personal biases about intervention in birth irrelevant.
To help birthing people achieve the birth they want, when their preference is physiological birth (with a safe outcome, it goes without saying), midwives must be skilled and knowledgeable about how to optimise physiological birth, monitor for any problems which indicate a recommendation for intervention, understand and offer information about all options, facilitate decision-making, escalate and implement interventions promptly and safely. They also need to be able to sensitively and candidly support families when they have not achieved the birth they wanted. Exactly the same knowledge and skills are needed to provide care when people are recommended or request interventions.
I would say that if there really is a harmful ideology present at times in maternity culture, it is a belief that we (the professionals and experts) know best, can tell birthing women what they should or shouldn’t do and have no need to really listen to them or take them seriously to inform our practice. Although nobody will admit to having this kind of attitude themselves, we have all witnessed it going on around us. This attitude often assumes an expertise which in reality is unfounded and more commonly based on experience of ‘how we do it here’ rather than an in-depth understanding of the evidence. And it is no more linked to ‘normal birth’ ideology than to a ‘medical model’ ideology.
It is really important that advocacy for birthing people’s choice and autonomy, and doing the best we can to support them to have the birth they hope for, is not equated with maternity staff providing unsafe or coercive care. Unfortunately, optimal care is not always achieved, and we do need more investment in skills and resources (rather than an ideological revolution) to ensure we all do our job better. Advocacy for physiological birth, when this is what birthing people want, must not be blamed for avoidable serious harms and death.
Thank you for your work. I hope that you’ve sent a version of this text direct to the investigation team. If they do their job well, supported by such insights, we may well have a better informed public debate on all this going forward 🤞🙏❤️