Defining and recording normal birth

AIMS Journal 2007, Vol 19, No 4

AIMS Chair Beverley Lawrence Beech looks for a more accurate definition of normality

In an article in 1997, Normal Birth does it exist?¹ AIMS questioned the accepted 'truth' that the majority of women in the UK have a 'normal birth' by speculating that, in fact, fewer than 10% of women actually do so because the so called 'normal' deliveries included women who had suffered inductions, accelerations, artificial rupture of membranes (ARM), epidurals and episiotomy. The article¹ created quite a lot of discussion and a midwife, Soo Downe, decided to test its validity. The research was designed to answer the question 'What percentage of births in the participating population which are categorised as normal or spontaneous would be classified as obstetric deliveries under the AIMS definition?' The research classed 'normal' births as births where the women did not have: Induction of labour, acceleration of labour, artificial rupture of membranes, epidural anaesthesia or episiotomy. In October 2001 Downe published the results of her research which found that fewer than 1 in 6 primigravida (first time mothers) and fewer than 1 in 3 women expecting subsequent babies achieved a 'normal' birth.²

The research added to the debate about 'normal', 'straightforward' births and obstetric deliveries and in 2005 the Royal College of Midwives launched its 'Campaign for Normal Birth' in an attempt to inspire and support normal birth practice in the midwifery profession and reduce unnecessary medicalisation.

Over the last two years the Maternity Care Working Party, chaired by the National Childbirth Trust, has been developing a consensus statement to encourage a positive focus on normal birth. Members of the working party include: AIMS, the Royal Colleges of Midwives and of Obstetricians and Gynaecologists; the Nursing and Midwifery Council; Association of Radical Midwives, the Independent Midwives Association; BirthChoiceUK, Birth Crisis Network, BirthCentre Network UK and a smattering of obstetricians, GPs and consultant midwives.

The Maternity Care Working Party was established to raise awareness of the public health implications of the rising caesarean rates and to campaign for improvements in maternity care and, after considerable debate, it produced a consensus statement about the need to recognise, facilitate, and audit normal birth.

One of the problems in determining just how many women really have a normal birth is the fact that normal birth can be perceived in a number of ways - ranging from no intervention at all, to any birth that did not involve, caesarean, forceps or ventouse (which means that those 'normal births' will include women who have had ARM, induction, acceleration, epidurals and episiotomies)and it is not always clear which definition hospitals are using when quoting their 'normal' birth rates.

In 2001 and 2002, the voluntary organisation BirthChoiceUK was able to obtain enough information from the Department of Health (DoH) to produce 'normal birth rates' for the majority of maternity units in England. From 2003 the DoH agreed to publish these normal birth rates in its annual Bulletin, which is now produced by the NHS Information Centre. It uses a working definition for normal labour and birth which they call 'normal delivery'. It is based on a specific set of routinely collected statistics. The definition is: 'without induction, without the use of instruments, not by caesarean section and without general, spinal or epidural anaesthetic [or episiotomy] before or during delivery.' While this definition is still not ideal it is a great step forward and will enable a better assessment of just how many normal births actually occur. It does not, of course, exclude from the definition acceleration, by drugs or ARM, and we intend, in time, to ensure that those interventions are excluded too.

In order to facilitate normal birth the Consensus Statement developed the following practical recommendations for action.

Maternity commissioners, providers and NHS Boards

• Maternity ser vices to set in place a strategy for supporting women to have a positive experience of pregnancy and birth and increasing normal birth rates, to be signed off by the clinical leads for midwifery and obstetrics.
• Active one-to-one midwifery support for all women during established labour, with midwifery staffing levels in line with the Royal Colleges' recommendation of 1.0 - 1.4 WTE (whole time equivalent) midwives per woman in labour, depending on case-mix category.
• Maternity services should aim to increase their normal birth rates towards a realistic objective of 60% by 2010, using the Information Centre definition.
• Access to antenatal preparation courses with a positive focus on practical skills for coping with labour pain including, use of active positions, access to birth pools, relaxation, massage and aromatherapy.
• Evidence-based information for women about factors that make a normal birth with good outcomes for the mother and baby more or less likely, presented in a format which they understand, so that they can plan for the kind of bir th they want and make informed decisions.
• Choice of place of birth including home birth, a midwife-led birth centre and a maternity unit with midwifery and medical facilities.
• The chance for women to get to know their midwife prior to labour.
• Consultant midwife and consultant obstetrician presence on the labour ward to lead and support staff.
• Comparative normal birth rates should be available for 'low risk' women planning and starting their care in different care settings (home, freestanding birth centre, alongside birth centre, hospital unit), using the principle of 'intention to treat'.
• Implementation of NICE evidence-based guidelines on Induction of Labour, Fetal Monitoring, Caesarean Section and Intrapartum Care in England, Northern Ireland and Wales.

Government policy, funding support and action by other national agencies

• Revision of 'Payment by Results' tariffs in England, as a matter of urgency, to remove the current per verse incentive to maintain high inter vention rates.
• Active one-to-one midwifery support for all women during established labour, with midwifery staffing levels in line with the Royal Colleges' recommendation of 1.0 - 1.4 WTE midwives per woman in labour depending on case-mix category, backed up in England by a Clinical Negligence Scheme for Trusts (CNST) requirement.
• Education and training programmes and mentoring to build the confidence of midwives to support women who wish to give birth without technological interventions
• All four countries of the UK to publish normal birth statistics annually using the same definition.
• Policy that services should increase their normal birth rates towards a realistic objective of 60% by 2010.
• Funding of research to establish how case-mix affects normal birth rates and the factors that facilitate normal birth, including inter-disciplinary working and referral arrangements, environments, size of unit, and organisation and qualities of care.

Normal birth rates for your local maternity units calculated using the Information Centre working definition can be found at www.birthchoiceuk.com and copies of the Consensus statement can be found at www.appg-maternity.org.uk

References

1. Beech, BAL (1997). Normal Birth - Does it exist? AIMS Journal, Vol. 9, No 2, p4-8.
2. Downe S, McCormick and Beech BAL (2001). Labour interventions associated with normal birth, British Journal of Midwifery, Vol 9, No 10, p602-606.