Come back, Ten Top Tips! Normal Birth needs you.

Once upon a slow news week in summer 2017, UK journalists lazily latched onto an out of date factoid: that RCM had axed its normal birth campaign (succeeded by Better Births back in 2014). All references to the campaign disappeared from RCM website in May 2017 – including theTen Top Tips for supporting normal birth. Three months later: cue a deluge of disinformation and inflammatory, inaccurate and non-evidence-based reporting on the ‘dangers of normal birth’, from which women need protecting, and the so-called ‘cult’ and ‘overpursuit’ of normality. Midwives were supposedly back-pedalling and backing down on normal birth.

Except we weren’t, and we aren’t.

For a start, look at why the normal birth campaign came about: a response to concerns about rising intervention rates and wide variations between different services in terms of planned and unplanned caesarean sections, and operative births, (NHS 2006; Thomas, Paranjothy & RCOG, 2001) as these procedures are known to be associated with physical and psychological morbidity (NCT/RCM/RCOG 2007). The normal birth campaign was an opportunity to share and promote good, evidence-based, practice.

Normal, straightforward, physiological birth is what most women want (Downe et al, 2015). Promoting normal birth and supporting all types of birth (and beneficial normality in birth of all kinds) are not mutually exclusive. Some women prefer or need caesarean or medical interventions for valid reasons, and a good midwife in her professional practice supports women in all and any births at which she is providing care: physiological, assisted, caesarean –always looking for possibilities and opportunities to maximize beneficial physiological process and humanize the experience.

Campaign against normal birth

Contrary to midwives’ internationally defined (ICM) scope of practice – which includes (but isn’t limited to) the promotion of normal birth, the campaign against normal birth tries to discredit, condemn and rename it out of existence – and by association, midwives. Hunt lauded the end of the normal birth campaign as a huge achievement for the Patient Safety lobby, making false and unjustified claims about its impact on neonatal outcomes.  A lack of factual correctness, which Prof. Soo Downe counters with a summary of evidence and facts regarding normal birth.

Sadly the post-truth era in which we now find ourselves means evidence doesn’t hold sway like emoting and making dramatic assertions. With political movements using all the resources they can to achieve their goals, including new technologies and social media (d’Ancona, 2017), indifference to truth has become the norm in politics, including the politics of birth and maternity.

Midwives are generally portrayed in the media as borderline incompetent; bad outcomes blamed on our bad practice, irrespective of cultural failings, bullying, staffing or socioeconomic and lifestyle factors. Short staffing and underfunding is responsible for patchy care, mistakes and the breakdown of the relationship between midwives and women – not an ideology of normal birth, nor a dearth of CTG hardware. Though the media presents it otherwise, briefed and influenced primarily by said Patient Safety lobby, it seems.

Is it the campaign against normal birth’s agenda to phase out and remodel midwives as obstetric nurses? Once and for all repositioning childbirth and maternity care out of a social context, into a medically-led, technocratic paradigm? From here, pregnancy and birth can be visualised within a pathology-focused spectrum of risk, and perceived as safest with increased technology, surveillance and maximum obstetric input. Why else allocate £4m for more CTG (a non-evidence based intervention) instead of investing in more midwives or midwife-led continuity models of care, which are known to improve outcomes and satisfaction? (Sandall et al, 2016)

A deeper mistrust of physiology

This suppression of midwifery isn’t due to pressure from obstetrics. In the UK, at least, RCOG is as concerned as RCM about over-intervention and the loss of normal birth (NCT/RCM/RCOG, 2007). We are allies, and this is about far more than doctors versus midwives. It’s more from a general antagonism towards women’s capacity to give birth, a deeper mistrust of physiology, the need of a paternalistic system to control birth (Donna, 2011), that myths generate.

“Myths are a construct which serve to denote the ‘cultural fabric’ of a group; a shared culture creates myths which support the beliefs and biases of the group” (Wood, 2004 in Phelan and O’Donnell, 2015)

Here are some of the myths about place of birth and safety, risk assessment and technological advances that are shaped by – and which shape – government policies, resources for maternity care and practices (Phelan and O’Donnell, 2015).

MYTH: Increased medicalisation of childbirth and obstetric intervention improves outcomes for all women and babies.

MYTH: Hospital is the safest place to give birth

MYTH: Caesarean section is now a safe procedure

MYTH: Ending campaign for normal birth will help government halve neonatal death and injuries (Hunt, 2017)

There is increasing evidence of over-medicalisation of healthcare resulting in the treatment of essentially healthy women, with straightforward low risk pregnancies ‘in whom potential benefit is small and likely to be outweighed by harms’ (Brownlee, 2017). The public is presented with partial information or information out of context, and the safety-medicalization-normality narrative is too complicated, and the detail too abstruse, to be understood by the uninformed. However, the media’s inadequate resources for fact-checking is no excuse for fraudulent, scare-mongering journalism.

If anything’s failing in our maternity system, it’s the system, not a woman’s body

“Healthy outcomes require respectful support for physiological processes, with medical intervention when needed or desired. The culture and systems of healthcare must ensure that women and their babies are given optimal chances of healthy outcomes without threat to their personal and legal autonomy.” (Birthrights’ Letter to the National Maternity Review, 19 August 2015).

A woman feeling like a failure because her birth falls outside the classification of normal points at two wider cultural problems:

1) Women’s actions being criticised; our incessant judging of ourselves. It’s not a failure to want an epidural, nor is it a failure to agree to induction, or need medical assistance in childbirth – some labours just need some help some of the time (Cronk, 2016).

physiology /fɪzɪˈɒlədʒi/ : the branch of biology that deals with the normal functions of living organisms and their parts – Oxford Dictionaries

Once the physiological process has been subverted by an intervention or clinical management, it’s not normal birth – no judgment.

2) Pathologisation of women’s bodies: An obsession with categorisation of risk causes an ever-narrowing window of normality during childbirth. Scamell (2012) observed how midwifery functions not to preserve normality, but to ‘introduce a pathologisation process whereby birth can never be categorised as normal until it’s over’. And what if women want to opt out of being ‘patients’ first, automatically medicalised and stratified according to risk?

To counter this reduction of birth to a mere spectrum of risk, we need a new way of seeing birth: Enter salutogenesis and unique normality

Salutogenesis – from the perspective of wellbeing; of what makes things go well, rather than from what makes things ‘go wrong’ (Downe and McCourt, 2004), and which encompasses a wider spectrum of variation within normal: unique normality. [This fits with the Better Births initiative, which highlights personalisation and choices; building care around the woman]

Unique Normality “takes account of each woman’s labour in the context of her pregnancy, her family clinical, psychosocial and emotional history and the story of her life. It sees birth as an ‘ordinary drama’ — not as a crisis, and not as a routine event, but as a one-off exciting event, full of possibility. In this approach, the task of the midwife is to maximize the possibility of normal birth, accepting that it will not always happen. Maximizing the possibility means opening up options to women, rather than closing down their expectations, and working with colleagues including peers, [supervisors of midwives], risk managers, obstetricians, neonatologists, and anaesthetists to see each labour as an opportunity for personal growth and development rather than a threat of complaint and litigation.” (Downe, 2006)

We override biology at our peril

Kloosterman (1982) Dutch obstetrics professor, describes normal, spontaneous birth as

“an event marked by a number of processes so complicated and so perfectly attuned to each other that any interference will only detract from the optimal character. The only thing required from the bystanders is that they show respect for this awe-inspiring process by complying with the first rule of medicine: nil nocere [do no harm].”

We should be looking for ways of working towards a model of maternity care which shows respect for this awe-inspiring process by complying with the first rule of medicine: nil nocere. Instead it feels as if we are moving in the wrong direction, away from optimum conditions for physiological mammalian birth that recognise that the physical and mental health of mother and baby are promoted by guarding against too much intervention too soon, quite as much as by guarding against too little too late (Brownlee, 2017). A belief that safety – and reduction of stillbirth rates – is increased predominantly by ensuring increased readiness to intervene, and greater use of technology, is widespread (despite the fact that 92% of stillbirths happen before labour starts, making much of this equipment useless.) Evidence demonstrates that public health measures to address health inequalities, and more women choosing to access midwife-led care, with continuity of carer, are key to a safer system with better outcomes for women and babies (Sandall et al, 2016; Guardian, 2015).

If the RCM’s Normal Birth campaign was ever misinterpreted by anyone to support acting unprofessionally, then that was wrong. Particularly as professional practice occurs in the context of NMC rules/code, ethical duties, local protocols and governance. But the campaign waged in the press against normal birth is out of all proportion to that risk. This, in itself, risks tipping an already overstretched system into an ever-increasing spiral of over-use of routine interventions, increased disappointment for women, and decreased knowledge about what is safe and what is not. Women expect the care they can get – that they are told to expect. If evidence-based information is overwhelmed by misinformation, what are women to do? How free and informed can their decisions actually be?

Support for normal birth is crucial to safe high-quality maternity care

Normal birth is a working term, a set of parameters. We need a precise definition to enable accurate comparison, early determining of deviations from ‘normal’ and timely referral. As an ordinary relatively newly-qualified midwife, a professional with expertise in normal birth, I am continuing daily to develop in supporting, facilitating, recognising and promoting normal childbirth – because I’m a midwife, and it’s my job. Undermining the concept of normal birth, even changing the name of it, is a retrogressive step for safe high-quality maternity care, and ignores the strong evidence base for supporting more women and babies to have a straightforward normal birth, and a positive experience of care. At institutional and policy level, we now have the challenge of trying to limit the damage by uniting around position statements, ethos and guidelines that don’t impinge further on women’s human rights.

Private, safe and unobserved

Yet we are sleepwalking away from the “intimate surroundings” (Gaskin, 2011) needed for optimising mammalian birth, those which are conducive to accessing the wild of women’s selves, and hormonal physiology (Pinkola Estés, 1992; Buckley, 2009).

Just as oxytocin – the childbirth hormone that makes uterine contractions – flows best when women feel private, safe and unobserved (Buckley, 2015), so the same quiet atmosphere needed for making love, is recommended as optimum for labouring humans; for normal biological functioning.

That’s why the Ten Top Tips were such an important aide-memoire for maximising physiological effects in birth.

They were part of a larger suite of information to help midwives in their practice, including the ‘off the bed images’ and a number of scenarios to help with reflection on clinical practice – never a stand-alone ‘guide to being a midwife’, and difficult to see how anyone would ever have thought of them that way.

I’ve always valued and practiced according to this resource to support mammalian biology and key aspects of ethical practice. For example, ‘Justify intervention’ means have an evidence-based reason, directly linked to observations of this woman and her labour and dialogue with her. All ten pointers support physiology, to avoid complications and unnecessary intervention – whether at home, midwifery unit or obstetric unit.

These are four of my favourites, in no particular order:

Build her a nest. Building a nest for a birthing woman develops the midwife/woman relationship, creating a safe space for her to birth in, where she can be her free, uninhibited self, tuning into her body’s needs and natural movements. Mammals –including humans – need warm, secure, dark places to give birth. If we revisit the basic physiology of birth and accept that it is hormone-driven (Chard, 1989, Russell et al 2003, Buckley, 2015), it becomes obvious why childbirth doesn’t work well in ‘laboratory’ – or hospital – conditions (Anderson, 2002). Mats and beanbags on the floor, lights dim, her own music, own pillows, whatever she wants, encouraging her to claim the space and make it as much her own as she can. By finding ways to help women to feel more private and confident, we greatly improve the likelihood of the normal hormonal flow of labour.

Wait and see is an approach that has always been accepted by the medical profession as a sensible approach to healthy individuals. It has been a central tenet of obstetrics, where women are labouring physiologically, as well as for midwives. One of last summer’s poorly evidenced articles (New Scientist) appeared to misrepresent wait and see as negligence, as ignoring signs or pursuing normal childbirth “at any cost”. It conflated the principle of wait and see with a lack of any monitoring, implying that wellbeing of mother and baby are not being regularly assessed. On the contrary, ‘wait and see’ is about working with women in labour, letting labour progress spontaneously when all is well, listening and paying close attention, following NICE initial and ongoing assessment recommendations, using clinical skills, patience, and a reasoned professional approach to recommending intervention instead of a ‘just in case’ approach.

Get off the bed. Gravity is our greatest aid in giving birth, making labour shorter, easier and more comfortable. Despite this, most women give birth on our backs. We need to be reminded that we can positively influence the course of a woman’s labour with alternatives to recumbent positions, encouraging her to find her own freedom and movement. Midwives are not necessarily energised and confident about facilitating upright maternal positions – and we could be more proactive. Some of the barriers to normal birth (such as routine pathological birth position) reflect lingering historical attitudes, habitual practices and organizational culture, as opposed to physiological birth evidence – that’s why these resources are so valuable.

and perhaps the most contentious and professionally challenging:

Trust your Intuition. Intuition is acknowledged to be a feature of expertise – for doctors as well as for midwives (Benner 2011; Quirk, 2006; Geraghty, 2015). Guidelines are about what is best across whole populations. Expert knowledge and intuition is about what is optimum for particular women and babies. Both are essential. Women go to midwives and to doctors for their expertise. If it was only a question of monitoring the heart rate, women could be attended by machines. In fact, the recent INFANT trial, where women at high risk were monitored by a machine that was programmed to detect fetal heart rate problems, did not perform any better than expert (‘intuitive’) judgement in this regard, and its use did not reduce stillbirth rates (INFANT trial, 2017)

Midwives practise careful observational skills for physiological signs along with intentional development of professional judgment skills learned through studying, being mentored and experience. And we also use intuitive knowledge (Fry, 2016), an ‘inner knowing’, which connects to spiritual care (Hall, 2012). Midwives relate to ‘something within’ them, an ‘inner calmness’ along with ‘knowing’ when to intervene – as do doctors (Greenhalgh, 2002). While intuition and evidence have long been ‘uneasy bedfellows’, GP and Evidence Based Medicine proponent, Greenhalgh suggested -15 years ago – that it was “time to raise the status of intuition as a component of expert decision-making” (Greenhalgh, 2002). The dichotomy between evidence based and intuitive decision-making was a false one – “surely the epistemological marriage we have all been waiting for”

What now?

1. Change the conversation: Move to a ‘both-and’ inclusive respectful debate that takes a clear-eyed look at all the facts, and not just those that fit with specific frames of reference (Downe, 2017). We need to drop the ‘either/or’ narrative, so instead of polarising, it encompasses both good outcome and good experience; both the woman and her baby; both the present and the future; both medical care and support for physiology; both honesty and recognition of complexity. No need for mutual exclusivity!

2. Take heart from midwifery heritage. Newcomers to the profession should research and honour the trajectory of midwifery and recognise the history of these age-old struggles; we have been here before. Midwives practicing in the 1970s and 80s were seen as radical because they covered over the windows of birth rooms to give privacy, and put the mattresses on the floor or for getting women to walk up and down, ‘allowing’ them to have a bath after birth, or dropping scissors on the floor to avoid doing routine, unnecessary episiotomies. Those midwives were taught to use our five senses first before technology. Observe – ask the right questions – listen to what the woman is saying. Basically everything encapsulated in the Ten Top Tips for normal birth.

3. Keep Human Rights central to quality and safety discourse in maternity. For midwives, obstetricians and maternity workers, this means understanding how human rights are relevant. This guide, Midwifery and Human Rights: a practitioner’s guide, produced by BHIR, Birthrights and RCM, provides accessible information about human rights, and how they are applicable in a variety of birth settings. It offers practical assistance when navigating difficult decisions which may impact on the human rights of the people we work with.

4. Keep Nil Nocere [do no harm] as a core guiding principle within maternity care. “The assessment of high quality, safe maternity care goes beyond measures of mortality or morbidity and encompasses multiple outcomes. For example, the most commonly used definition globally, and which is used by the WHO includes the following dimensions: women’s experience and woman-centred care, effective, efficient, equitable, timely and safe care. Using this definition, safer care is focused on services that ‘do no harm’ to those who use or work in them, rather than just focusing on the potential risk that women or staff create.” (Birthrights, 2015)

5. Take responsibility ourselves for normal birth. We need to review our own attitudes, beliefs and actions as a profession, remain committed in our everyday practice to innovate and provide more time and space for labouring women – despite the enormous pressures from austerity, staff shortages, lack of resources, pay cuts and increased workloads.

6. Soften. Listen. Humanise. Individualise. Personalise. Study evidence.

Marsden Wagner’s vision for maternity care:

“Maternity care needs turning around so that, instead of drifting away from normality, physiology and from the social and cultural environment, the process moves toward respecting and working with nature and with the woman and family, turning control of medical care over to the people. Eventually the new millennium will see a system of maternity services which are midwife-intensive, evidenced based, focus on out-of-hospital low-risk births, and honors the freedom of women and families.” [excerpt from Fish can’t see Water: the Need to Humanize Birth in Australia, Wagner, 2000]

Implementing Better Births – the maternity care transformation programme – offers us the possibility of many positive changes. Let’s hope that the press will, in time, come to share the understanding of evidence, and of the essential role of the midwife, that is at the heart of both the NICE Intrapartum Care guidelines and the internationally renowned Lancet Midwifery Series.

Thanks for sticking with it all the way down to here.

Olivia Silverwood-Cope RM BA BSc