There are growing conversations about helping women to have what is termed a ‘normal birth’, that is a birth free of interventions including no pain relief etc.

Years ago, for women giving birth at home, it was risky event, and as medical advancements were made it became viewed as the safe thing to do to be in a hospital, surrounded by midwives and doctors, being monitored and having tech of every kind to help keep mom and baby safe. However the down side of this has been the over medicalisation of birth.

With the increasing use of pain relief such as epidurals, and the monitoring of babies in birth, women soon became less mobile, positions such as laying on their backs with feet in stirrups became ‘norm’ leading to more inventions such as forceps and c sections. Women in turn placed their trust in the midwives and doctors to ‘deliver’ their babies safely, losing trust in their own bodies, hormones and the physiology of the birth process. The result being that birth became lost in a sea of policies and guidelines, and women and staff a like often feel confused and trapped in a system that while originally was there to support women, has become a place where avoiding risk comes at any cost.

So it is understandable why we need to remind families about physiology of birth, and why we need to empower women in their own abilities to birth their babies. Also why there is an emphasis on what is deemed ‘normal’ because often giving birth without intervention isn’t the norm. In fact we see many more interventions, traumatic births and poor maternity experiences.  

But this raises a few questions. What is normal and how do we define this? Are maternity services in a place where they can help support so called normal births? Is having a ‘normal’ birth what matters? What does matter to women when it comes to birth?

Normal??

Normal….. such an interesting word, its definition is, conforming to a standard, usual, typical or expected. It can mean something that’s common, conventional, fixed, or an expected state.

So how do we define a normal birth? This is hard as normal will mean different things to different people. Also depending on where you live, your culture and previous experiences, what is normal in birth will again be different. We have already said that what is not normal is a birth without interventions, and so the definition ‘normal’ doesn’t fit the way women often give birth today. So where do we base of definition of a normal birth if this has been seemingly lost?

The other thought around normal is that it hints at conforming, or an expected state. Would it be right to expect women to have a birth with no interventions or pain relief or worse to conform to this? Birth involves choice, women should be free to make informed choices that are right for them. There may be many reasons as to why a woman choses pain relief or interventions such as monitoring. So maybe defining any birth as ‘normal’ is going to be difficult.

Another issue raised is when we set something as the ‘norm’ or the standard to reach, or the expected state, we have to accept that some will not ‘reach’ this. Women often voice feeling guilty about many things and no more so than birth. Guilt over birth can run deep and cause harm to bonding, emotional wellbeing and the journey into parenthood. While we all want birth to become less medicalised and women to believe in themselves more, will we really achieve this by setting a standard that will for many be difficult to reach? After all there are many for whom the possibility of a ‘normal’ birth would be out of reach? Certain health conditions, baby being in a certain position or other medical issues may mean that attaining a birth without some invention is unlikely and maybe impossible. Many women express that they feel like a failure due to the birth they have experienced. That somehow not having a ‘normal birth’ somehow makes them less or weaker, even some have voiced they feel like they have failed their babies. This leaves many women feeling negative about their birth, even traumatised. This especially can be the case if women are given the impression that any one way to give birth was better than another, as a gold standard to reach and in reality it be something beyond their reach.

Supporting Normal birth?

I work in antenatal and the maternity unit and see the daily pressures faced by staff, an ever mounting paperwork pile, more births, women with more complex and challenging circumstances and higher expectations from on high, fewer staff, dwindling recourses and fear about litigation and safety. This raises the question, are our maternity services in a place to support normal birth?

Normal birth and the helping women to believe in their ability to birth their babies requires time, trust, building the of relationships as well as good antenatal education. Unfortunately this is difficult to provide in the current culture of maternity services. We cannot pursue the de-medicalisation of birth without the services to support women and staff.

Midwifery led units are much more available now but again the criteria is often so tight that few women are able to use them. Again with home births while we wish this is be an option open to women, providing the support to enable a woman to birth at home can be timely and complicated. It is a mistake to think that all we have to do is help make birth less medical to talk to women about the process of birth without looking at the services that women rely on to provide care while they give birth. Many women and midwives will state how difficult it is to give or receive even the most basic care, so while we all wish women to be supported to birth in ways that reduce interventions we need to accept that this will require massive changes in the way maternity services are currently run. Often the system is failing women, and this needs to be addressed too not just how women are giving birth.

Safety and litigation is something that comes up time and time again. The inquest into the deaths at Morecambe bay highlighted a number of reasons why care was lacking and families suffered.

When things go wrong and the worse happens families will of course want to understand how and why. Sometimes blame is sought and often staff can be caught between the two sides of supporting choice for women but also the problems of when things go wrong and the implications of this.

It is so important then that women are fully aware of the choices they are making, that they are given a clear understanding of the risks but also that there is adequate support in place for any choices they do make. This can be very difficult for staff especially doctors whose role is to provide care thats keeps a woman and her baby safe. Seeing a woman make a choice that they view as having great risk can be challenging and their professional head and training will be to want a women to be in the place that they feel they can support her best, namely hospital. This is where they feel they can keep her safest with tests and monitoring because this is what they know and are trained to do. This is not because they are against a woman having a normal birth but because they want a woman and her baby to be safe. This can help us to understand why they may feel differently about inventions and their role in birth. However helping everyone including doctors, to work along with a woman and her body can help everyone to find the right choices that keep everyone safe but also respect the wishes of the woman. Evidence based discussions regarding this are needed but also listening to each other, respect and co-operation on both sides.

Fear can play a role or women when it comes to birth, as can lack of understanding on how to help support herself and her baby be born. This is where antenatal education matters.

It can be patchy and often women report feeling unprepared for the reality of birth. It is a difficult balance to find that means we empower women to trust their instincts but also prepare them for if things change and how they can deal with this. Continuity in carer and building relationships with staff can go a long way in helping women feel confident and supported, however again this is difficult in the current system.

When we consider also the content of antenatal classes, are we covering just the info that covers normal birth or truly helping women to make informed choices regarding their care however they birth their baby?

Another important question to ask is are we involving women, co producing with them and asking them what they would like in antenatal classes to support them in their maternity experience?

Does ‘normal’ matter?

So does it really matter if a woman has a ‘normal birth’?

For some women and families having a normal birth matters greatly and they will do everything possible to prepare and make this possible for them. For others however it doesn’t matter how they birth as long as they and their baby are safe. Keeping women emotionally safe is just as important as keeping them physically safe in birth.

We need to support women in the choices they make, especially if this involves their emotional wellbeing. Choice is important. So when women, families have a choice and we must support this, no matter how hard that maybe.

Another angle is that for some sadly they may have very few choices when it comes to their birth. Emergency situations, babies born early, health conditions in mom or baby may mean that birth has to be medical. This is difficult enough for women to process and when all things are considered what matters is that mom and baby are kept safe physically and emotionally and cared for in the best possible way.

So what does matter?

While it is right to look at de-medicalising birth and helping women to educate themselves in regards to birth, we cannot view this the answer to ensuring a good maternity experience.

Birth is completely unique to each women each family. Woman are individuals with different personalities, needs, feelings, cultures, life experiences and desires. However what does matter, is care given. Wherever a woman gives birth, be it in a village in Africa, a igloo at the north pole, a beautiful flower filled meadow in England or in a high tech theatre, surrounded by the best tech money can buy, what matters is how she is treated, cared for and supported.

Women can have a normal birth, yet suffer due to neglect, poor care and unkind treatment. If this is the birth she doesn’t really wish for or feels she is she expected to have her experience will be affected. A woman can have a highly medicalised birth or a traumatic situation yet be ok because she is cared for, feels loved, respected and supported and vice versa.

So when it comes to birth what does matter? I guess the answer would be is what women themselves say. So maybe it would be good to ask them, so I have and I will cover this in my next blog.

What matters in birth?