Actions will speak louder than words in reported normal birth ‘back down’

Sheena Byron tweet August 2017
Strong disagreement over RCM’s position

News reports this week suggesting the Royal College of Midwives has “backed down” on its longstanding Normal Birth Campaign have been welcomed and celebrated by many, but it remains very unclear (even unlikely) whether anything new is happening at all.

I am cautiously hopeful, but mostly sceptical, about whether changing a campaign name will bring about the much needed reforms in maternity care quickly enough, especially given my concerns about the new Better Births initiative (Maternity services inquiry submission MS10035), but also because the RCM’s campaign work is so entrenched in national guidelines and policies.

What has the RCM said?

August 2017
On the RCM’s website (15/08/2017), CEO Cathy Warwick says its Normal Birth Campaignwas replaced by our Better Births Initiative, a broader based piece of work but still encompassing educational elements of our normal birth campaign“, 3 years ago.

She maintains that care by a midwife still includes “the promotion of normal birth“.

If women and babies are to be kept safe it is important that their birth, whether straightforward or complex, is kept as normal – or physiological or straightforward or optimal – as possible. Doing ‘too much too early’ can cause just as much harm as doing ‘too little too late’. The provision of high quality maternity care necessitates careful balancing of these two opposing elements… if governments are to ensure the safest care of women and their babies a critical underpinning element of this is to promote midwifery and midwifery led care within an overarching climate which ensures a positive multidisciplinary culture and ease of transfer between all providers along the pathway of care.

April 2017
Also, in a Times interview earlier this year (22/04/2017), Cathy Warwick is reported as saying, “there are no plans to stop using the word “normal” for childbirth without medical intervention such as pain relief, instruments or induction“.

There are words being used on our website which I’ve agreed that we need to modify so that they never imply that something is better than something else,” she said. “We won’t be changing our intention, which is to say ‘having the best birth for you will for many women mean having a normal birth’… Women giving birth are not saying ‘we want to get rid of this term’. If they were, it might give us something quite different to think about.

March 2016
But most importantly, the RCM’s  Survey Report ‘Interventions in Normal Labour and Birth‘ makes the intent of its new Better Births Initiative very clear:

There is also increasing interest in the potential benefits of optimizing the potential for physiological labour and birth for women/babies who experience complications in pregnancy, or even during labour. This is part of the intent of the RCM Better Births Initiative, which has three themes, including: The promotion of normal births for majority of the women and normalisation for all women (RCM 2015).

I repeat for emphasis, the RCM promotes “normalisation for all women” .

The report also says, “We recommend that each participating organization hold a series of consensus meetings with relevant staff to agree on a definition of normal birth and then to ensure it is recorded according to the agreed definition [note: focus on auditing the birth process remains].

“The proportion of women who gave birth normally without the interventions of interest [note: these include epidurals] was 39% overall. This supports the intent of the RCM Better Births Initiative (RCM 2015) in promoting the potential for women and babies with complications to experience a physiological birth without interventions.

The most recent UK NICE guidelines recommend that pregnant women at low risk of complications should consider giving birth outside of an acute hospital setting (NICE 2014).” [note the word ‘should’ in this sentence]


17-Aug-15 RCM FB page with comments on normal birth story - extract
Comment on RCM’s Facebook page this week


‘As You Were’

Reading the RCM extracts above, it’s likely that only terminology, and only in certain contexts, will change, but not the fundamental principles behind its campaign.

For example, the RCM’s current, updated, ‘Resources‘ website page begins with this quote:

Most women, in every country across the world, would prefer to give birth as physiologically as possible. For most women and babies, this is also the safest way to give birth, and to be born, wherever the birth setting. If routine interventions are eliminated for healthy women and babies, resources will be freed up for the extra staff, treatments and interventions that are needed when a labouring woman and her baby actually need help. This will ensure optimal outcomes for all women and babies, and sustainable maternity care provision overall.” (Professor Soo Downe, Professor in Midwifery Studies, 2014)

Again, I repeat for emphasis – the elimination of routine interventions.

The right of women to decline an offered intervention is one thing, but a national elimination policy for all ‘healthy’ (or ‘low risk’) women is entirely different.

And surely the burgeoning NHS maternity litigation bill is a much bigger challenge to sustainable maternity care provision than routine interventions?

Ideology Cost (death, injury, litigation)

Families are less tolerant of risk than ever before

Professor Susan Bewley, chair of the 2014 NICE CG190 Intrapartum Care for Healthy Women and Babies:

Doing nothing in the face of normality does not have to be justified… the onus of both ethical and clinical proof is on the interventionist side.” (BJOG 2002)

Campaigner and obstetrician Wendy Savage:
One of the problems… is that obstetricians don’t find it easy to say no when a woman says she wants a CS… women and their families expect everything to be perfect, and if it is not they are upset, and doctors are influenced by that. I think women and their families have to understand that life is uncertain.” (Guardian 31/03/2016)

Could this be where some normal birth campaigners are going wrong?

Compromising Safety

In The Times on Saturday, CEO Cathy Warwick reportedly denied claims that the RCM’s campaign may have “compromised safety“:

I am very sceptical that any midwife would ever have looked at what we were saying under the heading of a normal- birth campaign and thought ‘this is telling me I must push normal birth beyond the point of safety’.

In this example of a 2007/08 RCM publication, it says:

if policies, protocols, guidelines and pathways of care are too rigid and are unable to be applied flexibly, then there is a risk that midwives are unable to feel empowered to practice the art of midwifery. They need to use the intuition that experience and knowledge brings, to sense when a problem may or may not be occurring.

A fictional story about a breech birth is used to suggest midwives “trust your intuition within midwifery practice“, and opens up the following discussion points:

  • Applying guidelines appropriately and deviating from them when it is appropriate 
  • Explaining to women the limitations of evidence-based recommendations

It concludes with the “Top Tip – Trust your intuition“:

Most midwives base their antenatal care on national guidelines (National Institute for Health and Clinical Excellence, 2003) and local policies. ‘Trusting your intuition’ promotes these tools to be used flexibly – with busy caseloads that can be increasingly challenging. The intuition that Angharad would benefit from an extra visit at home enabled her to have the space and time to make informed choices that were right for her. Angharad made a choice that did not follow the current recommendations, i.e. the ‘safest way to have a baby in the breech presentation is by elective caesarean section’.

The story is given a happy ending:

Angharad tried to have her baby turned at 36 and 37 weeks’ gestation, neither of these attempts were successful. She went into spontaneous labour three days after the second attempt and arrived in the labour ward when her contractions were strong and regular and every five minutes. Her labour progressed quickly and David vaginally was born three hours later in good condition, weighing in at 6lbs 2oz. Angharad commented that although the birth was not as initially intended, she loved the experience and received all the support that she needed from her midwife during the labour and at the birth.

The question is whether, in practice, some midwives may have felt empowered by this type of communication to deviate from guidelines and recommendations ‘when appropriate’, and placed too much trust in their own ‘intuition’?

Restructuring Maternity Services

Regardless of the debate over whether the Normal Birth Campaign (by this name or any other) is officially on or off, what’s needed (and hopefully the government’s Maternity inquiry might help) is a fresh look at how maternity care is communicated and delivered, broadening the focus of responsibility beyond the RCM.

Policies and guidelines focus far too heavily on ‘place of birth’, assuming that this is every woman’s main consideration, when in fact ‘mode and timing of birth’  (spontaneous, induction, caesarean) are hugely important too.

NICE produces entirely separate guidance for vaginal and caesarean births, when in reality, the two are inextricably linked, and therefore guidance needs to be more combined (as I have always argued in my NICE Stakeholder submissions).

The NHS needs to put in place better measures of all health outcomes, to produce useful data that can help inform women of their possible and statistically likely outcomes of different birth plans (based on their age, parity, weight, family/medical history).

Birth literature and guidelines should avoid subjectivity in maternity care policies where possible (e.g. replace ‘unnecessary’ interventions with the more objective ‘unwanted’).

Caesarean birth benefits should be communicated (different to promoted or encouraged) alongside vaginal birth benefits, and where appropriate, the word ‘caesarean’ should be used in place of euphemisms when describing what would have saved lives.

NHS leaflets and websites need revisions to ensure information is broad and balanced.

Then let women decide.

  • Written by author and journalist Pauline Hull