Making Normal Birth a Reality

AIMS Journal, 2008, Vol 20 No 4

Beverley Lawrence Beech looks at the Normal Birth Consensus Statement

When campaigning to change the quality of maternity care one has to play a long game because it is rare for anything to change overnight - unless, of course, it enhances professional power.

For example, as a result of the flawed Hannah trial¹ (which compared caesarean section with a managed obstetric delivery, rather than a physiological midwifery assisted breech birth,) obstetricians are telling women that it is safer having a caesarean operation for a breech presentation. What they do not tell women is that the way obstetricians perform a vaginal breech delivery (the woman on her back, feet in stirrups and manipulating the baby as it is being born, sometimes with the use of forceps) can result in more damage than a caesarean operation. What the researchers in the Hannah Trial did not do was compare a traditional midwifery approach (the woman on her hands and knees and the midwife leaving well alone as the baby emerges) with the obstetric approach. Women are not told that skilled midwives can still offer a traditional approach to the birth and as a result this managed obstetric approach reduces the normal bir th rate and sets women up for subsequent caesarean operations.

In 1997 AIMS published an article² which claimed that fewer than 10% of women experienced a normal birth in hospital. The midwives were shocked (most hospitals claimed at least 60% normal births) so in 2000 Soo Downe decided to test the hypothesis and conducted a retrospective analysis of case notes in five separate consultant units in a par ticular health authority.³ Using the 1997 AIMS criteria for normal birth, she found that barely one in four women had a normal birth. This study excluded women who had induction or acceleration of labour, artificial rupture of membranes, epidural anaesthesia and episiotomy (those who had caesarean operations, general anaesthesia, forceps or ventouse would already be excluded) but included women who had pain relieving drugs, electronic fetal heart monitoring and syntometrine for the third stage of labour, all of which are excluded from the 2007 definition.

In 1999 a Maternity Care Working Party was created to act as an expert advisory body to the All-Party Parliamentary Group on Maternity and is chaired by the National Childbirth Trust. It has representatives from the Royal Colleges of Midwives, Obstetricians and Gynaecologists, General Practitioners and Nursing, the Association of Radical Midwives and the Independent Midwives Association as well as a wide range of lay groups including: AIMS, Baby Lifeline, Blooming Awful, Birth Crisis Network, London Health Link and National Baby Network.

The Working Party decided to develop a Normal Birth Consensus Statement and in 2007 produced an agreed document designed to encourage a positive focus on normal birth, see below.

Working Party discussions with the Information Centre (which collects national statistics) about the definition of 'normal', resulted in it adopting a working definition for normal labour and birth which it calls 'normal delivery'. It is based on a set of routinely collected statistics. The definition excludes induction (with prostaglandins, oxytocics or ARM,) the use of instruments, caesarean section and the use of general, spinal or epidural anaesthetic before or during labour. This definition still falls short of the AIMS definition of normal birth which would exclude ARM, acceleration, electronic fetal monitoring and a managed third stage.

The Consensus Statement is a first step on the path to obtaining statistics that really reflect the numbers of women having normal, physiological, births. In the future AIMS, and some members of the Working Party, expect that the 'normal delivery' statistics will exclude: ARM, augmentation of labour, use of opioid drugs, artificial rupture of membranes and a managed third stage.

In the meantime, the Consensus Statement makes recommendations for action and it calls for all NHS Trusts and Boards across the UK to use its definition and collect and publish the statistics regularly. It can be used to encourage Trusts to set in place a strategy for improving maternity care and enabling women to have accurate information about the numbers of normal bir ths (by its definition) that take place in their local unit. At themoment the normal birth statistics are highly misleading.

Copies can be obtained from parliamentary@nct.org.uk or call 020 8752 2396 or www.appg-maternity.org.uk

References

1. Hannah M et al. (2000) Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. The Lancet, 2000, 356, p1375-1383
2. Beech, BAL (1997) Normal birth - Does it exist? AIMS Journal Volume 9 No. 2 p 4 - 8
3. Downe S, McCormick and Beech BAL (2001) Labour interventions associated with normal birth, British Journal of Midwifery, Vol 9, No 10, p602-606