What is causing women to fear physiological birth? How the UK maternity system is failing.

AIMS Journal, 2025, Vol 37, No 2

By Emily Burke

With birth in the UK becoming an increasingly medicalised event, and intervention rates rising, many women who are pregnant are led to believe that they will not be able to birth their baby without some form of help. They no longer trust their bodies to be able to birth physiologically. This article will explore some of the reasons why this is and what can be done to protect physiological processes.

In the UK, interventions are generally accepted by pregnant women, healthcare providers, and wider society as a standard part of labour and birth care. There are a huge variety of risk factors that can lead to medical interventions being suggested even though in most cases the risk of harm is low, meaning most women will probably be offered some form of intervention during their pregnancy or birth but may not necessarily benefit from reduced risk.

Many different interventions will be offered throughout pregnancy: antenatal blood tests and scans; a membrane sweep or pessary to induce labour; vaginal examinations to assess labour progress; or a forceps delivery with episiotomy or caesarean section. While these and other interventions have their place and can positively impact outcomes, could offering them too early or too frequently take away a woman’s power to birth her baby herself, without first giving her the chance to do so? Providing women with antenatal information about potential interventions during pregnancy and birth is essential. How this information is delivered plays a significant role in shaping a woman's confidence in her ability to give birth. It should be shared early and presented clearly, allowing women ample time to reflect on their choices and make informed decisions that align with their needs.

Medical intervention rates are climbing, with 1 in 3 women in the UK being offered induction of labour. Caesarean and instrumental delivery rates are also increasing with 42% of women birthing this way in 2023-24 and rates continuing to rise.^[1] These rising numbers, and general acceptance that these interventions are a necessary part of birth, can lead to women being disempowered. Throughout pregnancy women receive a barrage of information suggesting that they will be unable to physiologically birth their baby. Constant reinforcement of this message leads women to lose trust in their own bodies, which in turn leads to them making decisions about their pregnancy and birth that may not be best for them, or what they truly want.

Studies have found that maternal attitude to birth is an important factor related to birth outcomes and working towards a positive experience of birth needs to begin in the antenatal period.^[2] Midwives are pivotal in the care and support of women, acting as advocates and keeping them at the centre of decision-making. A key aspect of this is ensuring that women are well informed about their options, empowering them to make confident decisions and maintain control of their experiences. Building a trusting relationship with women in their care can help midwives to provide support and advocacy. The continuity of carer model holds great potential for addressing these challenges. However, despite there being a target to fully implement this by 2023 in the UK, it has been hindered by insufficient staffing and resources.^[3] This has unfortunately resulted in gaps in care provision, highlighting the pressing need for systemic improvements to support this valuable approach.^[4]

Medical interventions such as induction of labour can affect women’s experiences of birth. This can have a significant impact on the mental health of women, with one study finding that primiparous women (women having their first baby) who had labour induced through administration of oxytocin reported higher levels of depression and anxiety in the postnatal period than women who went into labour spontaneously.^[5] The NICE guidelines recommend that induction of labour should be offered when there is a clear medical indication and the expected benefits outweigh any potential risk’^[6] however determining what constitutes a medical indication is not always straightforward.^[7] Most common indications for induction of labour are not supported by strong evidence, e.g. women with gestational diabetes, multiple pregnancy, suspected fetal macrosomia (very large for dates) or intrauterine growth restriction, and induction of labour does not always lead to improved outcomes.^[8] Even in cases where there is evidence that induction of labour might reduce risk, it would be necessary to carry out a very large number of inductions in order to avoid one poor outcome.

When women are consistently told during pregnancy that they may require an induction of labour, they can begin to lose confidence in their body’s natural ability to birth their baby. NICE guidelines published in 2021, recommend discussing preferences about mode of birth including induction of labour early on in pregnancy, meaning that women are potentially being programmed for longer to accept intervention.^[6] How this information is delivered can be significant. If the information is provided in a way that is a genuine discussion explaining what induction involves and implications for other birth choices this can support autonomous decision-making. However, if this information is not framed as a discussion about recommendations, this can result in a reliance and expectation on others to make decisions for them. Consequently, women may be more inclined to accept interventions without question when recommended by clinicians. This could lead to women consenting to induction of labour without being fully informed about their individual situation, or asking about alternatives. They could potentially feel that they were not given a genuine choice regarding their birth experience, even feeling that they have been coerced into accepting interventions if no alternative choices were offered.⁷

A further issue with maternity provision, particularly related to interventions such as induction of labour, is the reliance on estimated due dates without sufficient acknowledgement in the normal variation in gestation.^[9] As soon as women have their first maternity appointment, they are given an estimated date of delivery and are then bound by this deadline. If this date comes and goes, there is then pressure to accept an intervention to encourage labour. There are sometimes good reasons for interventions such as induction of labour, but there are situations where interventions are offered for reasons that are not evidence-based.^[10] Interventions can have consequences, such as leading to further interventions, and the benefits are often insignificant.^[11] Therefore, offering interventions could lead women to unnecessarily doubt their ability to give birth physiologically, without the benefit of a significant improvement in outcomes.

If a woman is offered an intervention and declines, this could lead to her being labelled difficult or stubborn by health care providers. She could be made to feel that she is putting her baby at risk, and that if anything were to happen to her baby then it would be her fault. Even when a woman has declined an intervention and this has been documented, she could be asked on several more occasions, each time having to stand her ground and justify her choices. Human rights laws give women the right to make their own choices about their maternity care and state that care providers must respect women’s freedom to make decisions about their care.^[12] Unborn babies acquire their own legal rights only after birth. When healthcare providers challenge or question a woman’s decisions, this could be seen as infringing on her human rights by trying to prioritise the rights of her unborn child over her own.

When it comes to caring for pregnant women, it is fundamentally important for care providers to empower women, building up their confidence and trust in their ability to give birth physiologically, without the need for intervention, and ensuring that women know they will be supported whatever decision they make. The possibility of needing interventions does need to be discussed with women and they should be provided with the information to enable them to make informed choices, however when and how these interventions are offered to women needs to be reviewed, along with how well they are supported if they decline care offered to them.

Striking the right balance between providing enough information for women to make informed decisions and avoiding overwhelming them is essential. Discussions about potential interventions during the antenatal period are important but must be conducted in a way that preserves women’s confidence and trust in their own bodies. They should feel empowered to believe in their ability to have a physiological birth if that is their preference, and healthcare providers must prioritise reinforcing this belief. Should an intervention become necessary, it is vital that women are provided with information about all available options in an unbiased manner and are then given time to consider the options to be able to make a well-informed decision about their care. It should also be made clear that they can change their mind at any time about decisions they have made and be supported throughout the decision-making process, no matter what they ultimately choose to do.

As birth in the UK becomes increasingly medicalised, it is essential to address the rising intervention rates and the subsequent impact on women’s confidence in their ability to give birth physiologically. Fear of physiological birth can leave women feeling disempowered and can cause issues long after the pregnancy is over. Care providers play a pivotal role in alleviating these fears by offering balanced and unbiased information, building trust in women’s bodies, and supporting informed decision-making. By prioritising compassionate, individualised care and challenging the normalisation of unnecessary interventions, the UK maternity system can help restore women’s confidence, reduce birth trauma, and protect the physiological processes of childbirth for those who wish to experience them.

Author Bio: Emily is a second-year student midwife with a passion for physiological birth and empowering women to have a positive experience of birth. She is particularly interested in how women can be disempowered and subsequently conform to what is expected of them by a medicalised structure and the people in it, and how midwives can support women and advocate for them to prevent this from happening.