Over the last week there has been lots of news relating to safety and maternity services. This was initially triggered by media stories relating to the Royal College of Midwives (RCM) signalling a shift away from using the term ‘normal birth’ and confirming that their normal birth campaign website was quietly taken down a few months ago. The RCM also confirmed that their much criticised ‘top tips for normal birth’ document was very recently removed from their current website and that neither this guidance or the normal birth campaign will be re launched.
The media reports quoted the RCM chief executive, Cathy Warwick stating that the normal birth campaign “had the potential to be misleading” and referring to the ‘top tips for normal birth’ document as “just not professional enough” adding “..they have gone; they won’t be reintroduced in any way and we’ll have much more professional, evidence based guidelines for midwives.”
Cathy also, for the first time I think, acknowledged that the language of ‘normal birth’ could make some women feel like failures saying: “It does seem that this word ‘normal’ is particularly contentious . . . it is simpler to use a non-value-laden word. Because of the inferences that are drawn there will be instances where you’re explaining your position better by using terms like ‘physiological birth”.
I’ve written about the RCM’s response to the Morecambe Bay Investigation which tragically made a clear link between the ‘..national agenda as dictated at the time…to uphold normality’ and the deaths of 11 babies and a mother here and more recently here. So in this context, when I read the comments from Cathy it felt like a very welcome and positive shift in emphasis.
The reaction to these media reports has been overwhelmingly positive, but there has been a strong backlash from some with accusations that the media reports were ‘fake news’ because of the fact that the RCM replaced it’s ‘normal birth’ campaign with it’s new ‘better births’ initiative three years ago.
Whilst this is true, I think it would be hard to argue that the normal birth campaign had really ceased until very recently. The campaign website was active until May this year and other documents, such as the RCM’s criticised ‘top tips for normal birth’ were transferred to the new website.
Old news or not, it’s clear most people weren’t aware of these changes, which have been welcomed by organisations such and Sands, Action Against Medical Accidents (AvMA), the Birth Trauma Association (BTA) and most importantly, women and families.
My son’s death in 2008 was not related to the mode of his delivery (he was born a healthy baby following a vaginal birth), but his death was characterised by midwives not communicating and involving doctors earlier.
After Joshua’s inquest in 2011, the Coroner wrote what was called a ‘rule 43’ letter, now known as a ‘prevention of future deaths’ report. I’ve copied a key extract of this letter below.
As the Coroner alludes in his letter, this was the second time he had had to raise similar issues. The other case the Coroner refers to is that of baby Alex Davey-Brady, who died at the same maternity unit where Joshua was born, just a few weeks earlier. This article from 2011, talks about what happened to baby Alex.
An independent investigation was commissioned into the maternity services at Morecambe Bay. In 2015, the investigation report was published. This found that 11 babies and one mother died avoidably at FGH (these figures included Joshua and Alex). The report identified (amongst a number of other serious issues) that “care in the unit became strongly influenced by a small number of dominant individuals whose over-zealous pursuit of the natural childbirth approach led at times to inappropriate and unsafe care”.
This finding of the Kirkup report has been met with denial from some. For example these words from the former RCM President, Lesley Page:
“The press has picked up on the report’s emphasis on “the ethos of normal or natural birth ‘at all costs’ at the unit which resulted in inappropriate and unsafe care” I searched carefully to find out what was the basis of this emphasis but couldn’t find much.”
The RCM have since clarified that they do formally accept the Kirkup report findings relating to Morecambe Bay, but they are adamant that their normal birth campaign was not a factor. This despite one of the witnesses quoted in the Kirkup report as saying “…there were a couple of senior people who believed that in all sincerity they were processing the agenda as dictated at the time… to uphold normality.”
A small, but influential group of individuals have responded with hostility and anger to the recent media coverage, for example Sheena Bryon writes here:
“…this post is referring to recent ludicrous press claims in several newspapers, of a non-existent ‘cult of normal birth’ by midwives, and that mothers and babies are suffering because of it. These stories are fear-mongering untruths, aimed at damaging a profession, and limiting women’s autonomy and choice. And, they are adding to the fear amongst pregnant women, that already prevails. Shame on you all.”
The blog post above is wrong to claim there is no evidence to point towards this issue either being real or not impacting on the safety of care elsewhere.
Parents of babies who died at Shrewsbury and Telford have relayed their fears that this issue was a factor in the tragic outcomes for them.
Recent media reports have highlighted that the number of claims for newborns suffering cerebral palsy or brain damage in 2016/17 was almost 4 every week, an increase of 23% from the previous year.
Of course, there are many factors that influence these outcomes. Staffing levels, continuity of care, availability of senior obstetricians and a culture of learning and supporting staff is vital. Safe and effective maternity care also relies on effective multi-disciplinary team working. However our experience, and the experience of many families I’m met over the years, is that there are some elements within the midwifery profession that don’t engage with the wider multi professional team soon enough, and this is sometimes influenced by an over zealousness to achieve a natural birth experience without any medical intervention
It would be wrong to claim this issue was the only important factor, that midwives alone were responsible or not to acknowledge that in some maternity units this may not be an issue at all. However, it is also completely wrong to dismiss the issues as ‘fear-mongering untruths’.
One of the most positive outcomes of the recent media reports around these issues, is that so many women and families have been speaking about their experiences. To improve care, we need to listen to experiences like these, not dismiss them.
We also need to listen to and not dismiss, the views of other professionals critical to providing safe maternity care – like those of Dr David Bogod who wrote the following letter in the Times this week.
Amongst the most powerful responses I’ve read, was this blog by Nicola Wainwright, a partner in Leigh Day’s Clinical Negligence team and sadly someone who works daily to understand why the most tragic outcomes occur. Nicola writes:
“…I am sorry to say I have met too many parents who did feel that their midwife’s ideology of achieving a ‘natural birth’ without any medical intervention, rather than their wishes or their and their babies’ safety, dictated the way their labour and delivery was managed….”
My plea for the future
I’ve been saddened by some of the responses I’ve seen in recent days, some of it directed at me. There is some irony that the people who claim that the recent media reports highlighting these issues are nothing more than ‘fear-mongering untruths, aimed at damaging a profession…and adding to the fear amongst pregnant women’, are the same people who promote phrases such as ‘obstetric violence’. Whilst it’s vital to recognise there are real and serious issues relating to intervention and consent, this language must terrify women and instil mistrust.
My personal belief however, is that the vast majority of midwives, doctors, women and families, recognise that whilst these issues aren’t everywhere, they do exist and change is welcome and needed.
My plea for the future is that midwives, obstetricians, paediatricians and anaesthetists work together collaboratively in the best interests of the safe delivery of the new born child, and that no unnecessary risks are taken because of any deeply held ideology. A natural birth is the aspiration of many – but not at any cost, and not at the cost of a mother’s or new born’s wellbeing.
There is a huge amount of good work currently happening to improve maternity services. The end of the RCM’s normal birth campaign can only help.