The cult of natural birth

Dear health secretary,

You must absolutely investigate the cases of women being denied analgesia. I would like you to also investigate the rising induction of labour and Caesarean section rates. Please look at the increased rates of instrumental births, rising PTSD and PND. While you’re at it, maybe take a look at the numbers of breaks missed by midwives, the hours we work late, the time spent sending important email referrals on our days off or responding to text messages during our annual leave. Please investigate the rising anxiety and exhaustion and sickness in midwives. Ask yourself why midwives (who train and excel, in general, in providing safe and compassionate care to women) are sometimes unable to look after themselves safely and compassionately. Ask yourself why we feel as though we are failing, why we are on our knees.

I want you to know that I have never denied a woman an epidural, but I have had to barricade a door to a labour room to prevent an anaesthetist from talking a woman into having one. The woman’s birth plan said she absolutely didn’t want an epidural, the woman herself told me she didn’t want one, and yet the anaesthetist wanted to come in and ‘sell’ one to her. I have absolutely seen some women not get their epidural in time. In general, this has been because their labour has progressed very quickly and their urges to push took over. I have also been in a situation whereby two anaesthetists on shift were unable to attend and site an epidural due to a very serious emergency unfolding on the ward. Twenty minutes after requesting an epidural, the woman was holding her baby in her arms. I came out of that birth with scratch marks down my arms from the woman who clawed at me. She consented to me touching her to facilitate the birth of the baby, but she dug her nails into the skin of my forearm anyway. I’m sorry that I was unable to get an anaesthetist to her in time, but I am not magic, and I cannot control labour.

I have cared for a woman whose cervix was fully dilated when she requested an epidural, and the anaesthetist tried to facilitate this. However, the woman was (understandably) unable to sit still enough to enable him to site an epidural and the anaesthetist had to abandon the procedure because his professional integrity meant he was unwilling to risk inflicting potentially lifelong damage by siting an epidural in a suboptimal situation. Have you seen the films and TV programmes in which women in labour hit a wall of emotion, a feeling so real and scary that you want to run away and keep yourself safe. It’s the moment that the woman says she can’t do it. She loses faith in herself and her body. This is transition. The woman is ready to give birth, and she needs to feel safe and loved and supported. This is sometimes the moment she says she’s going home, or when she cries for more pain relief. She says she wants an epidural because her instincts tell her she can’t do it, invariably it is too late at this point for an epidural, and even women birthing in a non-hospital environment might request an epidural at this point.

Requesting an epidural is every woman’s right, but we work within the realms of the National Health Service. We wait. We have a service that is free at the point of access. We wait. The doors are open and the care is there, 24/7, no questions asked. We wait some more. I’m going to be controversial: an epidural is not essential for labour, at least not always. Some women will tell you that birth is not painful, that it is powerful and orgasmic, and transformative. Others will tell you it is the most painful experience ever. Do we need a maternity system where we routinely offer epidural analgesia upon admission? I’m not sure what evidence there is to say that epidural analgesia improves women’s experience of care, or that their satisfaction with their labour or birth improves. The evidence doesn’t particularly matter in the sense that each woman brings her own evidence to the table during labour: if she wants an epidural, that’s what is right for her. However, it is an intervention, it is not without risk. How about we offer all women an elective Caesarean section under spinal or general anaesthetic? There’s no evidence to support this. For some women, an epidural is necessary to help them cope with labour. For other women, it isn’t. Having an epidural is an individual choice that we must facilitate when possible.

I am a community midwife and I spend a lot of my week discussing labour and birth with women. In my mind, a birth plan (or whatever terminology you use) is key to women’s experiences of labour and birth. A birth chat with the women in my caseload lays some of the foundations for how they approach labour and birth. We discuss the reading they have or have not done, what they hope to do or have or achieve, their plan A, and then we make changes if and when their plans change as their pregnancy progresses. Some women want to only focus on their plan A and do not want to discuss any other options. Other women want to run through their plans A to Z. Some women want to birth at home with a pool, with dim lights and soft music, surrounded by their birth partner and extended family. Others plan an epidural as soon as they are in labour. As for women being denied an epidural in early labour, can maternity units accommodate all women in early labour on their wards for an epidural to be sited? No. The evidence says that women who spend early labour (the latent phase) in a birth environment that’s not their own home are more likely to have an epidural, an instrumental birth, an operative birth. The research suggests a link, but not causality. It might be because we watch and intervene too soon as midwives if women spend early labour in a care environment, because early labour doesn’t follow a linear trajectory (nor does established labour, but there are artificial parameters delineating ‘normal progress’ in established labour). It could obviously be because women who access care earlier in labour are predestined to have more intervention, regardless of where they are or at what point they access care.

Let’s unpick why women are being ‘denied’ an epidural during labour: quick progression of labour, no anaesthetist available due to activity on the ward, lack of beds on an obstetric ward, a medical reason (sepsis, low platelets, spinal problems), problems siting the epidural, being in early labour, lack of staff able to provide the one-to-one care needed, anaesthetists’ refusal, midwives intervening in women’s decision-making regarding pain relief. I can’t do much about most of these. The latter point, I can work on in my own practice. I hope that I am a woman-centred, compassionate midwife, and I honestly don’t care whether women want to birth in a pool using hypnobirthing techniques, or have an epidural as soon as they are in labour, or opt for something along that spectrum. I care that women are in control and make decisions that they are happy with.

I don’t care what pain relief, if any, is used. I don’t mind what type of birth a woman has, I want her to have the birth that is right for her. I care that decision-making is woman-led and woman-centred, that the woman and her baby are safe and cared for, and that they feel safe and cared for. I want her to feel empowered enough to tell me what she needs, when she needs it. Paracetamol, a shower, a bath, TENS machine, hypnobirthing, moving, massage, dihydrocodeine, liquid morphine, pethidine, entonox, aromatherapy oils, birth ball, a peanut ball, a birth stool, a pool, remifentanil, epidural. There is an extensive list of things that can be used, but I will never routinely offer women an epidural. I will never tell them that labour is meant to hurt, that they are meant to cope, that they can’t or shouldn’t or mustn’t. I won’t tell them they have to or must, or that they (or their cervix) are ‘only’ 2cm dilated, or that they have a long way to go. I will respond to their needs and wishes.

Lack of epidural isn’t leaving “rising numbers in agony”. There aren’t rising numbers of pregnant women suddenly in agony. Labour is labour. Birth is birth. Evidence tells us that women who feel supported and loved and looked after have a more positive experience of labour and birth. The experience of pain is subjective. I spoke to a woman today whose husband was having a heart attack and declined the morphine offered to him by paramedics. Others would need that morphine. His choice was not right or wrong, but it was right for him. Pain is different for everyone. Some women don’t want midwives to refer to pain in labour as it’s suggestive, it has a negative connotation. Pain is bad and should be eradicated. Inflammatory articles in the press perpetuate the negative press that birth is receiving. It’s fear-mongering. Birth is painful, midwives are bad, your wishes won’t be respected.

There needs to be an investigation into why women’s choices are not being respected, but this does not end with epidurals. And it does not end with maternity care. Statistics cited in the article showing that epidural use has fallen from 67% to 61% over the decade from 2008-2009 to 2018-2019 is not a negative, and it does not necessarily indicate that the fall is due to women being denied an epidural. If we roll back 100 years, 0% of women had an epidural and home birth was the norm. If the press was sensible, they would question why 61% of women are having an epidural. They would look at the rates of instrumental and operative birth, they would question the long-term outcomes in terms of mental and physical health. Continuity of carer models are associated with lower rates of epidurals. This is a model being propounded as the answer: it will give women a more positive experience of care with fewer rates of interventions compared to women who do not have a continuity of carer model. If women who enjoy the benefits of continuity of carer are less likely to have an epidural, we should be dismayed that epidural use sits at 61%.

In my opinion, allegations of women being denied epidurals is possibly the tip of the iceberg and of course needs investigation, and focusing on epidural use will miss the potential failings in all sorts of areas of decision-making in maternity care. What else are we missing? The language used, the intimation that a procedure is necessary rather than recommended or just one of many options. We are meant to be striving for woman-centred evidence-based care. Why are we not also investigating the ways in which women are cajoled into accepting intervention because it suits a practitioner or a guideline or an anxiety?

What troubles me is the accusation of the cult of natural childbirth. Supporting women who opt for childbirth without pain relief is not a cult, but denying women analgesia must be investigated. Childbirth is (in general) normal and straightforward. Childbirth is normal, until it is not, and then we would want to intervene (with consent) to optimise outcomes. All outcomes. The psychological and physical health of the woman and baby. The woman is at the epicentre of all care, each interaction, every single conversation, all decision-making, any plan, any change.

Midwives are facilitators, with consent. We are with woman on her journey, for as long as she allows us to be, for whatever choices she makes. Every single choice that she makes is a good one if she has all the unbiased evidence-based information that she needs in order to make that choice without judgement and without pressure or coercion. Midwives, obstetricians, anaesthetists, must not pressurise women into or out of having an epidural. We must not impact women’s choices or tell them what to do or think or feel, in any aspect of her care.

The cult of natural birth. When are the newspapers going to decry the cult of medicalised birth? Birth that is led by obstetricians and measured in seemingly linear ways that don’t quite fit with how women’s bodies function. Birth that is initiated or augmented by pumping women full of hormones and fluid. Birth that occurs under bright lights, in a hospital gown, on a bed, under a scratchy blanket. Birth that squashes the pelvis, birth in lithotomy, birth that’s directed by midwives telling women to take a deep breath in and push. Births where babies are extracted by someone wearing scrubs rather than brought into the world thanks to a woman’s urge to push. Why are we not investigating the cult of medicalisation and intervention? The cult of dehumanising women, of throwing them into a faceless system that treats them as a statistic. The cult of moving women and birth from the home. The cult of midwives being vilified and natural birth being demonised.

We are a profession of individuals working as a collective to provide women with the care they want and deserve. We love and cry and feel with them. Midwife isn’t a job we do, it’s a thing we are. We live and breathe and are. Contemporary midwifery should not accept substandard care of women, babies or families. Action is needed to improve outcomes and experiences of care, and decrease medicalisation, because the medicalisation of maternity care has not always resulted in improved outcomes or improved satisfaction. While the Health Secretary is conducting this not insignificant investigation, I repeat that he must go above and beyond. He must analyse the system,

the media coverage of birth, society’s expectations and understanding of all birth, the stresses and strains placed on the shoulders of midwives. Midwives must play our part. All midwives caring for women and their babies must be held to account, we must hold a mirror up to our own practice and be honest. Do we have preconceptions about the ideal of how women should labour and birth? Do we enforce (whether consciously or unconsciously) those preconceptions on the women we care for? If so, we need to change.

We need to protect and advocate individualised, woman-centred, evidence-based midwifery care that is situated neither in the cult of natural birth at any cost, nor in the cult of medicalisation and intervention for no reason.