How a dangerous ‘normal birth’ philosophy could put Australian babies at risk
A string of shocking baby deaths in UK hospitals has exposed the risks of pushing for natural births over all else, raising concerns for Australian maternity care.
Should pregnant Australian women be worried? Australia’s system of maternity care has a great deal in common with the British National Health Service. Could ideology be putting expectant mothers – and their babies – in harm’s way in Australia’s birth centres and hospitals?
The Australian College of Midwives, in a recent submission to the Victorian government, wrote that while caesarean section could sometimes be a “necessary and lifesaving” procedure, it was “overused” and many women were undergoing “unnecessary caesarean sections”.
In the same vein, the Queensland government’s Normal Birth guideline states that “supporting normal birth for all women is a particularly important strategy to improve overall outcomes and reduce caesarean section rates in Australia”.
There are few greater responsibilities for a nation’s health system than the safe arrival of the next generation. Indeed, when UK Health Secretary Wes Streeting announced the latest national review he wrote that “maternity care should be the litmus test by which this government is judged on patient safety”.
Streeting was responding to an ongoing investigation into maternity care at the University of Nottingham, where the deaths of more than 2000 babies were being scrutinised. The scale of the tragedy was so great that police considered charging hospital executives with corporate manslaughter.
Streeting personally had spent hours with bereaved parents, listening to stories of loss not only of otherwise healthy babies but also, in some cases, of their mothers.
In response, he has ordered a rapid national investigation to finally provide “truth and accountability” for families and drive improvements in the standard of care.
At the same time, the British Nursing and Midwifery Council has written to universities across the UK, warning them to stop promoting “normal birth” to midwifery students.
As a working obstetrician for more than three decades, and former president of the Australian College of Obstetricians, I have never met a midwife or doctor who did not want anything other than the best for the women in their care.
Why, then, if maternity carers are so dedicated, do things go so badly wrong in so many maternity services in countries like the UK?
It was this drive to “normal birth” in the UK’s Shrewsbury NHS trust that saw 300 babies die or suffer serious harm and a dozen mothers lose their lives in childbirth.
Incredibly, only a few years earlier the hospital had been praised for having the lowest rate of caesarean birth in Britain. The parliament had been told that this “success” resulted from a policy of “treating pregnancy and labour as normal processes leading to a vaginal birth”.
In 2007 all the major groups charged with responsibility for maternity care in the UK – including the colleges of obstetricians and midwives – had signed up to a push for “normal birth”. At the time, the WHO was promoting a “target” of caesarean section rates of no higher than 15 per cent based on findings from low-income countries.
The drive to reduce the number of caesarean births across the NHS was very similar to the NSW government’s Towards Normal Birth policy rolled out in 2010 across its public hospitals.
That initiative flopped and was quietly dropped. At the start of the campaign the rate of “normal” vaginal birth in NSW public hospitals was 64.5 per cent, but it fell to 62.3 per cent by 2015. Over the same period caesarean rates increased from 25.6 per cent to 27.3 per cent five years later. At the moment the rate of caesarean birth in Australia’s public hospitals is just over 33 per cent.
In the aftermath of NHS scandals, the CEO of the Royal College of Midwives told The Times that some midwives had a “dangerous ideology that had gone too far”.
The release of an official report into Shrewsbury Hospital forced Britain’s Care Quality Commission to abandon any caesarean “targets”. By this time the WHO had long walked back its recommendations too.
Are Australia’s maternity hospitals following a dangerous philosophy of “vaginal birth or bust” in the quest for low caesarean-section rates at all costs?
Ten years ago in Australia the Djerriwarrh Health Service at Bacchus Marsh in Victoria came to national attention when failings in the maternity service were associated with the deaths of seven babies.
That scandal led directly to the creation of Safer Care Victoria, a state government agency that aims to partner clinicians with patients to drive improvements in healthcare safety.
The final government report into the Bacchus Marsh tragedies found that it was not any philosophy but, instead, the hospital’s governance systems that had let down pregnant women. The hospital’s administrators had been unable to monitor standards or respond to bad outcomes.
Maternity care in Australia is guided by a national policy document, Strategic Directions for Australian Maternity Services, which was published in 2019 and makes it clear that pregnancy and birth are “normal physiological processes”.
“Women’s choices are sought and respected throughout maternity care,” is one of the principles guiding care for mothers in this country. Choice, though, must be informed choice.
The good news for mothers-to-be is that Australia is one of the safest places in the world to have a baby. Even in the UK, the great majority of births are safe.
In a review of maternity services at East Kent in southeast England, where more than 100 babies suffered avoidable death or harm, there was still reassurance.
“Most mothers are healthy and, thankfully, their babies will be too,” it read. “But so much hangs on what happens in the minority of cases where things start to go wrong, because problems can very rapidly escalate to a devastatingly bad outcome.”
The report from East Kent went on to point out that in the pursuit of “targets”, staff did not take action when they should, and babies and their mothers were harmed, sometimes severely.
It was the targets themselves, zealously pushed by NHS managers, that had hamstrung midwives and obstetricians, putting pressure on them to place statistics above safety.
While Australian maternity services are not shackled to UK-style targets, official pushes to lower caesarean section rates still loom large over birth suites around the country.
The CEO of the British College of Midwives, Gill Walton, has now publicly stated that university midwifery courses should not promote ideology but, instead, promote the use of evidence.
In an interview published in The Times newspaper, she made it clear. “What we have to do is look at the woman in front of us and make the right decisions in partnership with that woman to keep that woman and her baby safe,” she said.
“We should be providing individualised care … based on the needs that the mother presents to us, not on any one ideology.”
It is critical that we find a way of balancing the wishes of potential parents with the capacity in our health system to provide the care they wish for.
Shortages of midwives and resource constraints in Australian hospitals continue to increase stresses in our maternity system.
With private maternity hospitals closing, the pressure on public hospitals will only increase.
Steve Robson is professor of obstetrics and gynaecology at the Australian National University and former president of the Australian Medical Association. He is a board member of the National Health and Medical Research Council and a co-author of research into outcomes of public and private maternity care.
The British government has called for an overhaul of midwifery training in the UK after a string of shocking scandals in maternity care. The heart of the issue is “normal birth”, and whether encouraging pregnant women to avoid caesarean sections is putting babies at risk.