Debate: Women and babies need protection from the dangers of normal birth ideology

AIMS Journal, 2017, Vol 29 No 3

Beverley Beech sumarises the debate between Professor Dietz and Professor Lesley Page

BJOG Debate: International Journal of Obstetrics and Gynecology, Vol 124, Issue 9, August 2017, p 1384 and 1385.

In August 2017 the International Journal of Obstetrics and Gynecology invited two Professors to discuss the claim that 'women and babies need protection from the dangers of normal birth ideology'. The first article was written by Professor Hans Peter Dietz, a professor of Obstetrics and Gynaecology who specialises in urogynaecology at the University of Sydney.

FOR: The recent maternity review risks making the situation even worse

In the first paragraph Professor Dietz referred to the Morecambe Bay Report, which he claimed caused 'concern over an ideology of vaginal birth at all cost' and that ‘forced …. a nationwide review’. He argued that 'Many clinicians saw this as an opportunity to set things right...'

He considers the Better Births' report to be a whitewash and Julia Cumberlege to be 'one of the most prominent advocates of the ideology that led to the problems chronicled in the Morecambe Bay Report'.

According to Professor Dietz the issue is always the same: ‘a culture of midwives [and sometimes obstetricians] promoting normal childbirth “at any cost’’—which means late intervention, or none at all.' He claims that morbidity and mortality have been modern medicine's top priorities and that the Cumberlege Report wants to reduce interventions further in order to reduce the cost of medical interventions.

He argues that ‘women are asking for more home birth, more midwifery autonomy, less intervention’ because they are given biased information, which keeps them in the dark about the risks 'because that might frighten them' and that this is not acceptable and this will have to change.

In his view the Cumberlege Report will offer a poor defence when judgements will be based on the 2015 Supreme Court decision in Montgomery v Lanarkshire, (which requires doctors properly to inform women of the risks) and 'is likely to make matters worse' suggesting that the introduction of privatised, independent midwifery, similar to that in New Zealand will also make matters worse, leading to unintended negative consequences and an increase in both morbidity and mortality.

Finally, he claims that 'Natural childbirth ideology is not just dangerous to women and babies, it is becoming dangerous to its adherents.’

The counter-argument was presented by Professor Lesley Page.

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

Professor Lesley Page, President of the Royal College of Midwives and the first Professor of Midwifery in the UK argues against the proposal, stating 'that support for normal birth as a dangerous ideology is to ignore the dangers of accepting birth as primarily a medical event that is prone to overuse of interventions'. The argument flies in the face of evidence-based policy and guidelines …. [and] ignores evidence of the risks of over medicalisation of health care’.

In challenging the medicalised view of threats to maternal and perinatal health, which can be described as “too little, too late” Professor Page suggests that the threats of over-medicalisation of normal pregnancy and birth can be described as 'too much too soon' and highlights examples which include ‘unnecessary caesarean section, the overuse of induced or augmented labour, continuous electronic monitoring, episiotomy and antibiotics postpartum. These, if overused, do not improve safety but increase risk of harm.’

In describing approaches to support normal birth, Professor Page points out the importance of respectful, compassionate and skilled care which aims to optimise the health of the mother and baby, taking account of physiological and psychological health and weighing up the risks and benefits of interventions and the long-term effects.

Finally, in pointing out that 'Normal birth’ is in a minority, and the rates are falling.' Professor Page states that 'The argument that women and babies need protection from the dangers of normal ideology ignores the strong evidence base for supporting more women and babies to have a straightforward normal birth, and a positive experience of care. Support for ‘normal birth’ is a crucial part of safe high-quality maternity care.’

AIMS Comment Professor Dietz’s argument appears to be based on the perception that women choose home birth and ‘vaginal birth at all costs’ because they are not informed of the risks and they need to be. He perceives the Morecambe Bay tragedy as exemplifying this, rather than an example of a dysfunctional obstetric unit.

He perceives the damage that many women and babies suffer is caused by a 'normal birth' ideology, and a reduction in intervention will lead to an increase in morbidity and mortality. It appears from his article that he is unaware of the growing evidence of the benefits of continuity of midwifery care and normal physiological birth, and the risks that he lists are precisely those that women face when they are required to book into an obstetric unit.

In contrast, Professor Page's justification of the 'normal birth ideology' is cogently argued and supported by frequently quoted research. Her paper also provides good explanations for the need to avoid ‘too much, too soon’ - when intervention is really not required, but it happens anyway, causing as much or more harm in terms of numbers of injured babies and mothers as the ‘too little, too late’ scenario.

The two original papers should be read by everyone involved in maternity care as they expose the blinkered thinking employed by those who seek to justify over-medicalised care, blaming it on what they perceive to be a ‘normal birth ideology’ rather than examining the adverse effects of over-medicalised, fear-based, care.

Note: Very few women achieve a straightforward normal birth in our obstetric units. A prospective cross-sectional prevalence survey of five consultant units in one region (Downe et al, 2001) found that only one in 6 first time mothers and only one in 3 subsequent births could be considered a straightforward normal birth. The ‘normal delivery’ statistics collected by the national Information Centre includes: augmentation of labour, ARM, electronic fetal monitoring and a managed third stage, an explanation perhaps for many over-inflated hospital claims of 40%, or more, normal births.

Downe S, McCormick, Beech BAL (2001). Labour interventions associated with normal birth, British Journal of Midwifery, Vol 9, No 10, p602-6.

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