Professor asks: is it ethical to promote normal birth?

Kudos to bioethicist Anne Drapkin Lyerly for the natural childbirth version of speaking truth to power.

Lyerly is is Associate Professor of Social Medicine and Associate Director of the Center for Bioethics at the University of North Carolina, Chapel Hill. She writes about social and moral issues in women’s health and reproductive medicine. She’s also on the Editorial Board of the journal Birth: Issues in Perinatal Care, published by Lamaze International. She has dared to question the ethics of “normal birth” within the pages of the premier journal of the normal birth industry.

The abstract succinctly summarizes her argument.

The concept of “normal birth” has been promoted as ideal by several international organizations, although debate about its meaning is ongoing. In this article, I examine the concept of normalcy to explore its ethical implications and raise a trio of concerns. First, in its emphasis on nonuse of technology as a goal, the concept of normalcy may marginalize women for whom medical intervention is necessary or beneficial. Second, in its emphasis on birth as a socially meaningful event, the mantra of normalcy may unintentionally avert attention to meaning in medically complicated births. Third, the emphasis on birth as a normal and healthy event may be a contributor to the long-standing tolerance for the dearth of evidence guiding the treatment of illness during pregnancy and the failure to responsibly and productively engage pregnant women in health research. Given these concerns, it is worth debating not just what “normal birth” means, but whether the term as an ideal earns its keep.

Lyerly explains the problem:

… [I]n its emphasis on birth as a physiological but not pathological or “medical” process, the concept of normal birth has served to highlight the harms of unreflective and routine medical intervention, and promote access to low intervention or what some have termed “natural” birth for women who desire it. Second, in its emphasis on birth as a social process, the concept of normal birth has helpfully promoted an understanding of birth as meaning imbued… [E]thically speaking, as an organizing principle for the good, the notion of normalcy raises a trio of concerns.


1. Not all women need or want a “normal” birth, and therefore, it is wrong to suggest that this type of birth is “normal.”

… “normal” indicates something that is normative or morally preferable—a state we ought to strive for. The result is a “fundamental tension” between normal as an “ordinary healthy state” and a “state of perfection toward which communities can strive.” In this way, the “normal” birth becomes (in hearts and minds) the good birth, potentially leaving women who use technology to conclude that they have somehow failed or missed out during their entrée to motherhood.

2. Why should avoiding technology be a goal when many women don’t want to avoid technology?

… [M]edical interventions— pharmacological or epidural analgesia, for example—can improve the experience of birth for women who desire them. In both cases, normalcy as a goal for populations does not track well with normalcy as an ideal for particular women. An unintentional and untoward consequence is that women who use and benefit from technology may nevertheless conclude that their births are somehow less than ideal, at a distance from a notion of the “good” that was either out of reach or inconsistent with their values and preferences.

3. The emphasis on “normal” birth as a socially meaningful experience misses the point:

… [A]re not all births, whatever the degree of intervention, socially meaningful? … Among the approaches {Diony Young, Editor of Birth] lists are respectful care, antenatal education, support in labor, informed choice and consent, supportive environment, evidence-based information and practice, mother baby togetherness, and availability of midwives for
one-to-one care… [N]one is specific to normal birth—that most if not all would be beneficial to a childbearing woman regardless of how medically complicated or involved her delivery.

… [N]ormalcy raises particular problems from the standpoint of justice, to the extent that it fails to attend to the needs of those who are disadvantaged, physiologically or otherwise. Some
prominent theories of justice require attention to, in some cases priority for, the interests of the least well-off. My concern is that the linking of social and psychological meaning and the nonuse of technology under the umbrella of normalcy implies that in complicated pregnancies, the social aspects of birth are somehow less relevant. Of course, they are not; indeed, women who face birth and illness together feel perhaps more pressingly the need for supportive, respectful care.

4. Many women experience pregnancies that are not normal. Natural childbirth advocates simply ignore these women, reinforcing the tendency of researchers to ignore these women.

… [I]n a 2010 Research Forum held at the National Institutes of Health entitled “Issues in Clinical Research: Enrolling Pregnant Women,” the tag-line read “Pregnant Women Get Sick, Sick Women Get Pregnant.” Of course they do—but that it was an extremely effective phrase was a telling reminder of our myopia when it comes to illness and pregnancy.

Lyerly’s critique, while measured and understated, is nonetheless devastating. It’s especially powerful because Lyerly takes NCB advocates at their word that they are acting on behalf of women and demonstrates that it’s fatuous to claim to be acting on behalf of women when you ignore, marginalize and denigrate a substantial proportion of them.

I agree with Lyerly that the promotion of “normal” birth is ethically suspect. However, the reason is simpler than Lyerly supposes. It’s money.

Midwives, doulas and childbirth educators can only make money from births that involve minimal or no technology. Therefore, they have idealized the births that represent their profits. The promotion of “normal” birth is a marketing strategy, no more and no less. Like Mitt Romney and the 47%, NCB advocates they believe that it is “not their job to worry about those people” who want services other than those that midwives, doulas and childbirth educators can provide.

NCB advocates recognize that increasing their profits involves creating a demand for their product. They are no different from the myriad of other purveyors in the marketplace who imply that their products will lead to social success and approbation. “Buy PearlyWhite toothpaste and you will get the girl!” translates to “Have a normal birth and you will be happier, empowered and have healthier children!”

Lyerly is clearly a less cynical person than I am. That makes her critique all the more powerful. She takes NCB advocates at their word and finds their word to be ethically suspect.