Viewpoint

Photo: courtesy of The Baby Experience Ltd. Instagram: @the_baby_experience

The Ockenden report, commissioned after a shockingly abnormal number  is heartbreaking to read. Terrible mistakes were made, communication was awful (between midwives and obstetricians, and between medical practitioners and parents), blame was shifted and lessons weren’t learned. The litany of failings is depressing to read. But what the report does not state is: “Three hundred babies lost to a fixation on natural births”, as the Sunday Times headline screamed. Other editors followed the same tack. 

“Natural” birth was the scapegoat for multiple failings. But the words “natural birth” only appear once in the report, in a quote from an unnamed mother, lifted from an earlier report on the same trust: “I felt that my concerns during labour were not addressed, that I was made to have a natural birth when an emergency c-section was more appropriate just so they didn’t dent their precious natural birth rate target.” 

The fact is “natural” can be a misleading word in this context. It should really only be used to mean a birth that hasn’t involved any form of drugs, forceps, surgical cuts, or other medical interventions. But for many – if not most – people it’s interpreted as a vaginal birth – no matter the level of “unnatural” elements involved.

When I read Ockenden wearing my doula hat, it’s clear the unnamed mother meant she was made to have a vaginal birth against all her instincts and that her misgivings weren’t heeded (failing to listen to mothers was one of the most distressing aspects of Ockenden and of the Mid Staffs scandal).

But there’s often nothing natural about a vaginal birth in an overstretched, understaffed health trust that relies heavily on interventions. Under such circumstances, c-sections become essential to manage the inevitable crises. And I should make it absolutely clear no midwife or doula I know opposes caesareans, which are life-saving miracles when carried out judiciously – and can be preferable to inductions, especially with older, first-time mothers.

What many of us do find hard and demoralising is that deaths of babies and mothers are blamed on an obsession with natural births when the evidence simply doesn’t support this claim. Lurid headlines claiming midwives think mothers are “too posh to push” have become a way to divide women into polarised camps – and to generate social media hits.

What’s not reflected on is whether it’s less “natural” than a caesarean to pump a woman full of drugs, strap her to a bed so that she can’t move, and harass her for hours with vaginal examinations and bleeping machines, before screaming at her to “PUSH, PUSH!” Eventually, pulling her baby from her helpless body with forceps or ventouse (sometimes after a brutal episiotomy). But this is a common image of a vaginal birth. We see the words “vaginal”, “normal” and “natural” used interchangeably – and almost invariably wrongly.

But the media know “natural” can be weaponised as a key word to maximise social media hits by dividing women into polarised camps. 

Their assertion that the NHS has a dangerous fixation with natural births is a myth. The Royal College of Midwives ran a “campaign for normal birth” between 2005 and 2014, partly as a result of mothers in the late twentieth century vocally complaining about over-medicalised births.

As ever, individual experiences varied widely, but the number of interventions kept increasing anyway. UK induction rates are now around 30 per cent.  And contrary to media scaremongering about mothers who schedule caesareans in advance, to fit in with their work (as well as to retain “designer vaginas”), fewer than half the babies born in the UK get to choose their birthday. 

There should be less scaremongering and more listening. For nearly 20 years as a birth educator and doula, hundreds of women have told me how they were cajoled, bullied or scared into an induction of labour which led to a forceps delivery or a caesarean.

Ockenden is right to stress that Trusts should not be penalised for high caesarean rates, since targets never work well in maternity services and local populations can vary. But it’s all a bit academic now, since the caesarean rate has gone from 23.2 per cent in 2005 to over 30 per cent today. Even so, normal birth “obsessives” carry the blame, although Ockenden has far harsher things to say about the Trust’s understaffing, bad management, high staff turnover, poor training, overstretched services and lack of up-to-date equipment – all things which can be sorted out by better funding, not by ideology. 

But “lack of funds” isn’t a sexy, headline-smashing story. It doesn’t fit the media’s preferred narrative of witch-like midwives cackling as they consign mothers and babies to their deaths.

Three huge elephants in the room have been shockingly under-reported. One is the overuse of the drug Syntocinon, or artificial oxytocin, to start or speed up contractions. “Synto” is the big gun of “vaginal birth at any cost”. Synto contractions can sometimes become so hard, fast and close together that the baby can’t recover in between them and loses oxygen. An emergency caesarean may be the only way to save that baby. Afterwards, the woman may be told she was lucky the doctors saved her baby – nobody likes to point out that the baby was saved from an intervention that probably shouldn’t have happened in the first place. 

The second elephant is the question of monitoring in labour. Usually this means the dreaded CTG monitor: clumsy, bulky transponders strapped round the woman’s middle with elastic straps like your great-granny’s knicker elastic, the other ends plugged into a cumbersome machine like a relic from the 1960s Lost in Space TV series.

The straps slip about and the woman is often told she should try “not to move so much,” although the urge to change position is instinctual because it helps ease labour pains and prompts the baby to move down (some claim belly-dancing originated as a strategy to cope with labour). It’s hardly surprising that many mothers who’ve been tethered in this way ask for an epidural.

That may come as a blessed pain relief, but also brings its own problems such as an increased chance of forceps delivery. It also means the CTG monitor becomes the most important thing in the room, with the woman coming a poor second and midwives spending up to a third of every shift dealing with bleeping equipment.

You would have thought, in the age of bluetooth and fridges that alert you to buy milk, someone might have worked out an affordable way of monitoring a foetal heartbeat which allowed a woman to squat, shimmy, or have a deep warm bath. But, no, wireless monitoring is rarely available in the NHS. 

The third, deeply troubling, elephant is the recommendation that Trusts should stop trying to provide “continuity of care”: the model by which a mother is seen by the same midwife team throughout her pregnancy. Yet this contradicts decades of evidence.

Many of the failings at Shrewsbury and Telford, including the tragic baby deaths, started with poor antenatal care and a failure to listen to women and identify their risks properly. Continuity of care, not technology, is one of the most effective ways of stopping women from slipping through the cracks.

But how can the NHS provide continuity when the number of midwives actively practising has dropped to critical levels, hugely increasing the risk of poor outcomes. In April 2021 a Tory health minister admitted that NHS England was short of 2000 midwives, eleven years after David Cameron promised as a 2010 election pledge to raise midwife numbers by 3,000. The sad truth is that for every 30 midwives the NHS trains, only one stays in the job because working conditions are often unbearable.

A survey of midwives published in November last year revealed 60 per cent were considering leaving the profession. Morale, following the Mid Staffs and Shrewsbury findings, is now at an all-time low.

I suspect the issue outstripping all others when it came to Shrewsbury and Telford’s maternity services, was cost. Caesarean sections are the most expensive mode of birth (home birth is the cheapest) and a reluctance to perform them almost always has more to do with budgets and hospital diktats than crazed midwives pursuing natural birth agendas.

There was a distinct lack of money during Jeremy Hunt’s years heading the NHS, during which it suffered the lowest funding increases since the 1980s. This may explain why Jeremy Hunt himself preferred to join the lobby against “natural birth”, rather than acknowledge the impact of his own budget-slashing. 

Here are some other facts that may surprise you. Low-risk women in the UK have a better chance of a safe outcome in a midwife-led unit within a well-equipped hospital than in a consultant-led unit. And low-risk women who have birthed before have a better chance of a safe outcome at home (Birth Place Study, 2011).

In the Netherlands, women are only referred to consultant-led units if they want to be, or if their risk level rises; the default option is home or a midwife-led unit. Nevertheless, the Netherlands has fewer baby deaths per 1000 than the UK. They also have well-structured post-natal support.

Here, women have to fight to be “allowed” to birth at home and have no support offered even after a caesarean. European countries with lower caesarean rates than ours also have lower maternal and infant mortality rates. 

These are not the products of dogma or ideology, but facts thrown up by research and internationally accepted statistics. But no politician seems able to accept that experienced midwives who are not dog-tired and have time to listen are safe carers, while demoralised midwives working back-to-back shifts, covering for sickness and staff shortages, reduced to fiddling about with monitors instead of watching the woman in labour, are not. Instead of a considered, balanced and intelligent approach based on experience, it’s easier to scream “burn the witches!” all over again.

Sarah Johnson is a birth educator, doula and founder of The Baby Experience Ltd. An author and journalist, she is the former children’s books editor of The Times.

Instagram: @the_baby_experience