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


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:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Maternity care should be patient-centered, not midwife-centered.[/pullquote]

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.


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.


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.