New natural childbirth motto: Safety Third!

Safety first on blackboard

The natural childbirth movement has unveiled a new motto:

Safety Third!

No, not really, but they might as well have made it their motto.

Yesterday I wrote about midwife Hannah Dahlen and her various cold blooded statements about perinatal death, especially:

[pullquote align=”right” color=”#c89f1e”]To hear many midwives and natural childbirth advocates tell it, the first and most important priority is the mother’s birth experience.[/pullquote]

When health professionals, and in particular obstetricians, talk about safety in relation to homebirth, they usually are referring to perinatal mortality. While the birth of a live baby is of course a priority, perinatal mortality is in fact a very limited view of safety.

A reader, Houston Mom, jokingly described Dahlen’s approach as “Safety Third!” and the more I thought about it, the more apt it seemed as a motto for the entire natural childbirth movement.

Experience First!

To hear many midwives and natural childbirth advocates tell it, the first and most important priority is the mother’s birth experience.

As Caroline Bledsoe and Rachel Scherrer note in The Dialectics of Disruption: Paradoxes of Nature and Professionalism in Contemporary American Childbearing:

… As childbearing became safer and more benign visions of nature arose, undesired outcomes of birth for women came to consist of a bad experience and psychological damage from missed bonding opportunities. Today, with safety taken for granted, the new goal has become in some sense the process itself: the experience of childbirth… (my emphasis)


If nature is defined as whatever obstetricians do not do, then the degree to which a birth can be called natural is inversely proportional to the degree to which an obstetrician appears to play a role. The answer to why obstetricians are described with such antipathy thus lies not in the substance of what obstetricians do that is unnatural … but in the fact that obstetricians represent a woman’s loss of control over the birth event…

Many midwives and natural childbirth advocates certainly believe this to be so. Dahlen is shockingly explicit about this belief:

Women have told us there is something worse than death – there is being alive but dead inside. There is being so traumatised by pressurised interventions in their birth plan that … their own mental health is affected.

Worse than death??!!

Ask any woman whose baby has actually died and you will find that there are vanishingly few women who believe that there is something worse than the death of their babies. Dahlen’s claim doesn’t reflect reality, merely the central conceit of those in the natural childbirth industry.

Providers’ Experience Second!

The providers’ experience is dramatically more important in the midwifery/natural childbirth paradigm than in obstetrics. Even a brief look at the midwifery literature confirms the central role of the midwife’s experience. Several years ago I did an informal analysis of the papers in various midwifery and obstetric journals. I found that anywhere from 20%-50% of papers in midwifery journals are concerned specifically with the midwife’s experience, whereas only 0%-8% of papers in obstetric journals mention the obstetrician’s experience.

For many midwives, process is deemed more important than outcome and the ideal process is one that affords the midwife maximum scope for practice and profit. Natural childbirth has come to be defined as “anything a midwife can do” regardless of whether it happens in nature or not.

A rather bizarre confirmation of the centrality of the provider experience among natural childbirth advocates is the existence of counterfeit midwives who have awarded themselves the designation “certified professional midwife” or CPM. These women are laypeople whose only education requirement is a high school diploma, and they fail to meet the minimum international standards for midwives. Not only are these counterfeit midwives allowed to practice in nearly half of all US states, the organizations that certify and represent them have NO safety standards of any kind. Safety is simply not a priority for CPMs.

The other confirmation of the centrality of the “provider” experience is the importance of the payor experience. The British National Health Service is desperately promoting homebirth despite the fact that it is not safe for a substantial proportion of women and despite the fact that 95+% of women have absolutely no interest in delivering far from medical expertise or pain relief. No matter. The ability of the payor to save money (even if those savings are subsequently dwarfed by massive monetary payouts for injured and dead babies) is considered more important than what women actually want or what is safest for babies.

Safety Third!

These factors relegate safety to third position in the hierarchy of natural childbirth values.

Partly it’s because natural childbirth advocates are profoundly ignorant of the medical and historical realities of childbirth. Childbirth is and has always been, in every time place and culture, a leading cause of death of young women and THE leading cause of death of babies. Childbirth in industrialized countries in 2015 appears safe, but only because of the liberal use of obstetric interventions. Without them, childbirth is inherently dangerous.

Mostly, though, it is because many midwives and natural childbirth advocates actually believe that both the maternal experience and the provider experience is more important than whether a baby lives or dies. Not surprisingly, in cultures like UK midwifery where this ugly philosophy is allowed free rein, there are a never ending series of scandals involving preventable perinatal and maternal deaths followed by midwives’ attempts to cover them up.

Modern obstetrics is not perfect. No one knows that better than an obstetrician like me. But at least obstetricians have their priorities in order. Safety of mother and baby comes first. Period. That’s why female obstetricians choose liberal use of obstetric interventions for themselves and their babies. That’s what is safest.

The truth is that safety ought to come first. That doesn’t mean that the mother’s experience is irrelevant; just that it is not as important as her safety and the safety of her baby unless she explicitly claims that her experience is more important to her than whether the baby lives or dies. The providers’ experience ought to be irrelevant. The preferences of midwives ought to be no more important in the provision of childbirth care than the preferences of neurosurgeons in the provision of brain surgery. Making midwives’ experiences equal to or more important than safety is, in my view, grossly unethical.

Ultimately, it is up to individual women to decide what is important to them. If you prioritize safety (and the vast majority of women do), then safety takes precedence. Before choosing providers, you should understand for many midwives though it’s “Safety Third.”