The British Medical Journal publishes a blistering critique of UK maternity care

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Childbirth in the UK—it’s time to be honest about what the NHS can deliver is the title of a powerful piece in the BMJ. It’s written by Dr. Laura Downey. In her day job, she “provides assistance to governments … for health system strengthening and improving the value for money of healthcare investments…”

She writes:

Maternity care should be patient-centered, not midwife-centered.

I gave birth to my daughter at an NHS hospital in London three weeks ago. As a public health professional … I consider myself fairly well informed about how the system should work. I understood the information and advocacy tools available to me and knew I could use them to inform my decisions throughout pregnancy and childbirth.

It turned out, however, that like so many other women who give birth in NHS care across the country, I was misinformed.

How?

The publicly available national clinical guidelines and myriad information leaflets handed to me throughout my pregnancy led me to believe that I had some agency in my own “birth experience,” such as choice of pain relief or mode of delivery. I did not.

What happened instead?

Antenatal care clinics run by midwives actively shepherd women towards giving birth “naturally” in their local birthing centre, where there is no access to epidural pain relief or obstetric care. This push for a “natural” or “normal” birth also precludes women from undergoing a caesarean section delivery under any circumstances other than a medical necessity. While such practice is not in line with NICE guidance, it is common across the NHS for hospitals to put in place local procedures that do not allow maternal requests for caesarean sections, even where a woman has asked for one because of a previous traumatic birth, an underlying medical condition, or because they’ve experienced past sexual trauma. Furthermore, in circumstances where women choose to leave the birth centre in favour of an epidural, many are denied their request for this mode of pain relief.

Midwives substitute their personal beliefs for patients’ needs and requests, even when that conflicts with official policy.

Moreover:

The language around birth and persistent use of the words “natural” and “normal” in the UK belittles the birth experience of many women and is both socially harmful and offensive. There is no shame in pain relief and mode of delivery bares no reflection on a woman’s worth… It is crucial for women to be supported by the health system to feel that they have agency over their own body and what happens to it during birth, especially if the alarming statistics about birth trauma and PTSD in the UK are to be addressed.

The only thing that surprises me about Dr. Downey’s observations is that it took so long for someone in a position of authority to recognize what thousands of women have been suffering for decades. I’m not sure why anyone expected anything different from the longstanding Royal College of Midwives “Campaign for Normal Birth.”

Promoting normal birth is about promoting midwives at the expense of patients.

You won’t find any real medical professional who insists that he or she “promotes” one treatment over another. Ethical medical professionals promote health and safety, not the opportunity to line one’s pockets or increase professional autonomy.

Normal birth has nothing to do with normal and nothing to do with birth. The definition of normal birth is simple and straightforward: If a midwife can do it, she calls it normal. If she lacks the skill to provide the needed care, she insists that the birth is not normal even if it results in a healthy mother and a healthy baby. “Normal birth” is nothing more than a marketing term for promoting midwives.

Most women don’t fall for it. British women resent the fact that access to obstetricians is severely curtailed. They despise the fact that such practices have led to the needs and desires of mothers being ignored. They are not alone. Dutch women go to other countries to give birth rather than settle for midwife led care; there has been a precipitous drop in homebirth, now down to only 13%. And the majority of American women, regardless of the availability of midwives, choose obstetricians. Indeed, there are not enough practicing obstetricians to accommodate all the patients who want them.

Here’s what Downey recommends:

A logical starting point towards improving women’s experience of childbirth in the UK would be to redress the imbalance in patient information and clinical reality to close the gap between what is promised and what is delivered. Transparency is key to empowering women to make their own evidence based choices about childbirth and what is right for them and their unborn child. However, information is meaningless unless women are kept fully informed about what they can reasonably expect. If the level of clinical care promised to expectant mothers deviates in any way from publicly accessible national or local guidance, women need to be made aware of this from the outset so that they are informed and prepared, and care providers can be held accountable.

I have a better idea:

Make maternity care patient-centered, not midwife-centered. Re-integrate midwives into the healthcare system: have obstetricians supervise midwives instead of letting midwives run their own private fiefdom for their own benefit. Midwives have been allowed to run patient care and patients have suffered as a result.

In other words, put obstetricians — not midwives — in charge of maternity care.

  • Voly

    “Re-integrate midwives into the healthcare system: have obstetricians supervise midwives instead of letting midwives run their own private fiefdom for their own benefit.”

    This is why I have chosen CNM group practice, operating from a large hospital with a birthing center, with OBs and Anesthesiologists on site to give birth. CNMs order the same tests as OBs, but end up spending more time talking to you (I had gone to an OB before, then switched due to insurance changes) during appointments, and have better availability to talk to you on the phone when you have problems. But I know that if there are any complications, they will send me to an OB MD straight away, and one will be available at all times during childbirth.

  • mabelcruet

    I’ve had a quick look at the usual suspects twitter feed: not a mention of this anywhere. They are wittering on about vaginal seeding and microbiome and discussing an article that appears to suggest the risks of vaginal seeding after section are exaggerated, on the grounds that the baby would have been exposed to these anyway if it was a vaginal birth (but they don’t seem to have grasped that one of the reasons that a section may be carried out is precisely because of what is carried in the vagina).

  • Michael Ray Overby

    My Group deals with Monochorionic Twins & Multiples exclusively. These issues, namely forcing Mummy into what they call “Natural Normal Birth” despite the established fact that VB is far more risky to mother & babies than to the singleton, are quite common & represent the biggest issue facing NHS regarding pregnancy & birth. Ignoring the fact that Shared Placenta Twins & Multiples represent a special case that just won’t go away & Conform to Policy is not the way to proceed and points up the general Attitude of UK NHS towards it’s pregnant clients. Pregnancies are not all the same,verily, all are in some way unique. NHS’ failure to recognize this established fact is already costing them money. Keeping the midwives in control of NHS Policy will soon become prohibitively expensive as court awards for screwing up in pregnancy pile up.

    • Daleth

      Even here in the US I was pressured by my MFM team to attempt vaginal birth. Even though the guidelines here are that mono-di twin moms have to labor in the operating room, due to the extremely high risk of needing an emergency CS.

      I don’t think that pressure is usual for mono-di twin moms in the US, but I was at a major maternity hospital where the doctors’ attitude was, “Whatever goes wrong, we’ll still save all of you, so don’t worry.” I was like, I actually believe that, but I don’t want to spend however many hours worrying about what might go wrong, or any time at all in a state of terror… So let’s just go ahead and schedule the CS, shall we?

      I had to bring in an inch-thick pile of printed-out studies to underscore my determination to get a CS. Then they finally scheduled it. Even so, a week before it was scheduled the head of MFM tried again to convince me.

      • rational thinker

        That is extremely unethical, what assholes!

  • Her position seems to be “tell us what the real deal will be” – rather than, we really need to bring services up to snuff. The problem isn’t with maternal request cesareans or pain relief, the problem is with the denial of access to these very things, things that women deserve to have access to.

    • PeggySue

      I kind of thought — well, maybe I HOPED — that she feels if the truth were told from the get-go then patients would raise such hell there would have to be change. Perhaps so, if her experience of finding out how it actually works only too late is the norm. Imagine if every patient was told at first visit, “We don’t do epidurals for any reason, you just need to cope with the pains. And we don’t allow c-sections except for extreme emergency. Yes, we know that’s not standard of care, but we don’t care, we’re in charge and you’ll do it our way.”

    • Sarah

      It is, but she’s also writing that in the context of a wholesale slashing of NHS funding in real terms this decade. It is happening across the NHS and is a matter of deliberate policy. I suspect she’s attempting to anticipate arguments about why should obstetrics get more funding when x, y and z specialisms are still being cut. Fucked up as that is, it is how things are in the UK at present.