Risk, Ideology, and ‘Normal Birth’

On Saturday 12 August 2017, The Times published a piece by Chris Smyth on changing attitudes towards terms such as ‘normal birth’ in the UK, which has sparked a chain of letters to the editor, a controversy in the blogosphere, and a range of follow-up articles from publications like The Guardian and the Evening Standard.

The original article interviews Professor Cathy Warwick, chief executive of the Royal College of Midwives (RCM), and discusses the college’s recent decision to abandon their ‘better births’ campaign in favour of more neutral terminology. This change of tone comes in the wake of the Kirkup Report which unveils facts about infant deaths (and one maternal mortality) at the Morecambe Bay trust. James Titcombe, whose son Joshua died from an infection which was not reported, was quoted as saying that midwives often make critical decisions without performing risk assessments. The implication is that they do not consider alternative (medicalised) means of delivery and instead favour an idealised — yet often unattainable — notion of ‘normal birth’.

Responses from midwives have, understandably, been indignant, and the sources of their outrage are numerous. For one thing, lack of funding from the NHS means that midwives are under pressure to perform in an already labour-intensive occupation; as one blogger observes, changing one word does little to overcome the realities of underfunding and staff shortages, which are more likely to lead to medical mismanagement. Furthermore, the same midwife illustrates how there may be a misunderstanding about the definition of ‘normality’: “by ‘normal’”, the writer stresses, “I am meaning unfettered by routine prodding, poking or general interventions”. In this instance, then, normality is not seen as a comparative measure of worth between pregnant people, but rather as the lack of unnatural and unnecessary hypermedicalisation by medical staff.

Statistics are also a cause of concern for some midwives. The Times‘s leading article concludes with the fear-inducing observation that Britain has one of the highest infant mortality rates in Western Europe. Yet a list of evidence and facts by Professor Soo Downe OBE repeatedly shows that so-called ‘normal’ births are rarely causes of death — and, furthermore, that pregnant mothers in the UK are at a significantly lower risk than those in the United States of America. (Childbirth is more deadly in the USA than any other developed country.) This is corroborated by research displayed in an exhibition by our partners at the Thackray Medical Museum, which shows how maternal mortality in the UK is now extremely rare.

The leading article may lack nuance, but it does highlight an important reason why both journalists and midwives should rethink their language usage: risk. Firstly, the rhetoric of normality risks presenting some mothers as failures, which may impact upon their psychological wellbeing. For this reason, midwives should question whether ‘normality’ really is the most appropriate term to use — and, if so, then they must articulate how this word should not carry any ideological undertones. Second, it is imperative for the media to stress the risks of both physiological births and medical interventions; while it is true that childbirth is safer now than it ever has been before, it is also vital to remember that procedures like caesareans carry their own dangers.

As a collective of academics and practising midwives, we invite responses from our members and readers: what do you think of the term ‘normal birth’? How should the media approach such issues, particularly when conveying medical information to a non-specialist audience?