NHS health chiefs instructed maternity departments to move away from a drive to promote so-called “normal” births – vaginal births without medical intervention – more than two years ago.
But on the frontline, maternity units remain divided by an ideological battle over the best way to give birth.
Now, i can reveal that NHS hospitals are continuing to place job adverts for midwives who will “promote normality”, and a safety investigator has said potentially dangerous attempts to discourage women from medical assistance during childbirth are widespread. i has identified eight such adverts that were placed in 2024, some as recently as this month.
“Promoting physiological birth [another term for “normal” birth] regardless of risk has been a consistent finding in major investigations into failed maternity services,” Dr Bill Kirkup, an obstetrician who has led two inquiries into avoidable maternity deaths, told i.
“Normal” birth bias – the belief that women should strive for vaginal births without medical assistance – has been criticised by numerous healthcare bodies in the past decade, after a series of avoidable deaths of mothers and babies at UK hospitals.
NHS England has told all hospitals not to put women off having Caesarean sections to boost their rates of vaginal births, and official guidelines say women have a right to choose Caesareans even if they have no medical need.
Caesareans can be life-saving if the baby gets stuck during labour. That being said, they can also can take longer to recover from, and raise the risk of infections and complications in later pregnancies, research has shown.
In 2022, Gill Walton, the head of the Royal College of Midwives (RCM) apologised for its part in promoting “normal” births that contributed to the deaths of mothers and babies, admitting that some midwives had promoted an ideology that had gone too far.
But belief in the superiority of “normal” births has persisted under different guises, according to evidence gathered by i, and testimony from safety experts and campaigners.
Many hospitals continue to advertise jobs for midwives that suggest the hospitals encourage women to have “natural” births – saying, for instance, that the applicants will be expected to “promote normal births” or “physiological births”. The terms “normal”, “physiological” and “natural” birth are generally used interchangeably to mean a vaginal birth without any medical assistance.
Some hospitals recommend women use ineffective alternative therapies instead of standard medical approaches – for instance, offering aromatherapy if the labour isn’t progressing, which goes against medical guidelines.
What are “normal” births?
The terms normal, natural and physiological births are often used interchangeably to mean a vaginal birth without medical interventions.
A birth would not be classed as “normal” if the woman had an epidural for pain relief, where strong drugs are delivered into the back. But most would still consider it a “normal” birth if the milder painkiller of gas and air is given.
If any instruments are used, such as forceps to pull out the baby, this also would not usually be considered a “normal” birth.
A damning report on the NHS this month by former Labour health minister Lord Darzi singled out maternity services for poor care, citing evidence that different healthcare staff have “divergent curricula”, in other words, are taught different facts. Dr Kirkup, the person who provided that evidence, has now told i, that by this, he meant that some staff training has a dangerous focus on promoting “normal” births.
“Whenever curricula for different staff groups are developed in isolation, there is potential for them to drift away from each other,” he said. “Promoting physiological birth without sufficient regard for the individual circumstances of risk is one example, perhaps the most obvious.”
In 2024, women are no longer supposed to be pushed into “natural” births, so how can practice in the labour wards be so at odds with official policy?
The debate over the best way to give birth has been ongoing for decades. Those who favour “natural” births say interventions such as Caesarean sections if the baby gets stuck can be overused and that labour is more likely to go well if it is interfered with as little as possible.
“A lot of the medical interventions that we impose on women, they also cause harm,” said Katherine Hales of the Association of Radical Midwives, a group that is in favour of natural births. “Lots of women have a horrible experience because they go through a medicalised process that is soul-destroying.”
The best known advocate of the “natural” birth agenda may be the National Childbirth Trust, a provider of antenatal classes for pregnant women, whose original name was the Natural Childbirth Trust. While the NCT’s official stance today is that it supports women giving birth however they like, those who attend the antenatal classes say the teachers often discourage medical assistance.
What may be less well known is that from the 1990s onwards, the “natural” birth agenda was gaining ground among university-based midwifery researchers and campaigners and over the next decade became baked into policy documents for professional bodies for midwives and doctors.
A key development was when NHS guidelines encouraging hospitals to boost their rate of so-called normal births were released in 2012, produced in partnership with the Royal College of Midwives (RCM) and the Royal College of Obstetricians & Gynaecologists, and the NCT.
Called “Focus on normal birth and reducing Caesarean section rates”, the document highlighted the UK’s rising Caesarean rate – which was 24 per cent in 2006 – and offered hospitals a range of measures to try to cut it to 20 per cent and ideally 15 per cent.
The guidance claimed – without good evidence – that this would reduce rates of death and harms from childbirth, as well as bringing the NHS financial savings.
“The purported reason for it was that it was better for mums and babies to deliver vaginally. In reality, it was cost-driven,” a former obstetrician, who i is not naming, said.
The Caesarean rate – which has continued rising since 2012 and is now at 31 per cent – is often a flashpoint in this debate.
Yet, doctors also acknowledge Caesareans are being pushed up unavoidably by multiple demographic factors that make successful vaginal birth less possible, including the trend of women having children older, as well rising rates of obesity and diabetes.
Other medical interventions that some say are overused include medicines given to induce labour, and epidurals, an injection into the back that is the most effective form of pain relief for labour.
But the dangers of pushing “normal” births too much has become more evident in the past decade, as the UK saw a series of maternity safety scandals, often in hospitals that had striven hardest for low Caesarean rates.
There have now been three hospital trusts in the UK where the number of mothers or babies who died or were seriously harmed during birth triggered official inquiries into what was going wrong.
The first was at Furness General Hospital in Morecambe Bay, where 11 babies and one mother were found to have died needlessly, the inquiry reported in 2015. “There was a growing move amongst midwives to pursue normal childbirth at any cost,” said Dr Kirkup, who led the Morecambe Bay investigation.
There have since been two similar maternity safety scandals, at two linked hospitals in East Kent and at Shrewsbury and Telford Hospital – which for years had publicised its low Caesarean rate of 14 per cent, compared with the national average of 23 per cent at the time. One East Kent mother said: “I felt 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 fourth – ongoing – inquiry, into a series of maternity deaths at Nottingham University Hospital, looks set to be the largest yet, involving nearly 2,000 families where there has been either a death or serious harm suffered.
In a progress report on Wednesday, investigator Donna Ockenden said that a common theme was staff failing to give medical interventions fast enough. This included refusing to accept that women really are in labour and turning them away from the hospital – something found to have contributed to the death of baby Harriet Hawkins at Nottingham in 2016.
‘We need to make sure there are no more avoidable deaths’
A father whose baby died during childbirth in 2016 due to failings by staff at Nottingham University Hospitals has said he believes “normal” birth ideology was a major contributory factor. “Some of the mistakes were rooted in the idea that birth is overmedicalized,” he told i this week.
Sarah Hawkins was in labour for six days, but despite pleading with midwives on the phone, she was told not to come to the hospital. On one occasion she did come in, but was given strong painkilling medication and sent home again. “We were both completely confused,” said her husband Dr Jack Hawkins. “We had gone to the experts and they had said, ‘Calm down, you’re fine.’”
When parts of the membranes covering the baby started being expelled from the womb and became visible, the couple realised they had to go back to the hospital. But when they arrived, in the middle of the night, the midwives on duty failed to treat it as an emergency.
In fact, the visible membranes should have led to Ms Hawkins being urgently examined, in case the membranes were concealing a trapped umbilical cord – which would have cut off Harriet’s oxygen supply – or a foot, indicating an emergency Caesarean section would be needed, said Dr Hawkins. “We should have been met by the consultant obstetrician ready to take us directly to theatre.”
Instead, Ms Hawkins was taken to a midwife-led birthing suite – intended only for women who are at low risk. The midwives started setting up a bath for a water birth and debated which aromatherapy oils would be best to use, while Harriet was probably dead or dying, said Dr Hawkins.
When staff tried to listen to Harriet’s heartbeat, they could not detect it and a doctor told the couple Harriet had died. She was delivered stillborn, nine hours later. An external review of the case found that staff had made 13 errors and concluded the death was “almost certainly preventable”.
A few weeks before this happened, one of the last things a doctor at the hospital told the couple was: “Don’t let anyone medicalise your birth,” according to Dr Hawkins. “That is an ideological statement. It is not a safety statement. They should have said, ‘Make sure that your baby is safe.’
“I’ve got a medical view of things, and I accept that that is not necessarily useful for everybody, but we need to make sure there are no more avoidably dead babies and avoidably dead mums.”
Tracy Taylor, former Nottingham University Hospitals chief executive, has previously said: “I profoundly apologise that we let [the Hawkins family] down so badly.”
Idealisation of “natural” births is behind beliefs that medical assistance is overused and women should stay out of hospitals for as long as possible, said Emily Barley, whose baby Beatrice died at Barnsley Hospital in 2022. “Nobody said, ‘We don’t want any interventions and we are happy to watch a baby die.’ But every concern I raised over many hours, I was told, ‘It’s just normal birth, everything’s OK.’
Bodies such as the RCM say that understaffing also contributes to poor care. In response to a critical report on maternity services out this week from the Care Quality Commission, the RCM’s Gill Walton said hospitals had “too few staff with the right training, too little time to care for and listen to women, and crumbling infrastructure”.
Of course, “normal” birth ideology is only one factor causing avoidable deaths, said Dr Kirkup. “There are many other factors, including poor teamworking, uncompassionate care and failure to learn from safety incidents.”
But most healthcare staff would agree that those kinds of problems need to be rooted out – “normal” birth ideology still has many supporters, said Catherine Roy, co-founder of the patient campaign group, the Maternity Safety Alliance.
While the hospitals that have triggered inquiries so far draw most of the flak, Dr Kirkup said similar attitudes are widespread. “High-profile failing units are the symptom, not the root of the problem,” he added. “The same features are present elsewhere.”
There are signs of change. Two years ago, all hospitals in England were told by NHS England’s chief midwife to stop trying to lower their caesarean rates, a key driver of attempts to boost “normal” births.
Yet in many hospitals, staff on the ground have not changed their ways, suggests Ms Roy’s work monitoring job adverts for midwives. In 2024, eight such advertisements seeking midwives who want to promote “normal” births have been placed, all from different hospitals to those that have been investigated so far.
In August, for instance, Maidstone and Tunbridge Wells Hospital placed an advert for a midwife that said “normality is promoted in all clinical areas”. A spokesperson said: “We understand there may be differing views on the language used in midwifery job adverts and will be carefully reviewing this going forwards.”
Similarly, Walsall Healthcare placed an advert in July, which sought a midwife who would promote normality and the use of alternative therapies. Joselle Wright, director of midwifery, gynaecology and sexual health at the trust, said: “The safety of women and their babies is our main priority, and staff continue to follow the most up-to-date national birthing guidelines to ensure quality and consistency of care throughout pregnancy, birth and the months that follow.
An NHS spokesperson said: “The NHS has a duty to provide safe and personalised care to women and families according to best practice guidance and informed by evidence, and it is a fundamental requirement of maternity teams to inform and listen to every woman, respect their views, and help them to achieve the type of birth they would like.”
A Department of Health and Social Care spokesperson said: “Women need to know their wishes are being respected and listened to when giving birth and it is unacceptable that too many women are not receiving the maternity care they deserve.”
The use of complementary and alternative therapies can also be a sign that hospitals prioritise avoiding evidence-based medical interventions, said Dr Jack Hawkins, whose baby daughter died at Nottingham in 2016.
Perhaps the most high-profile such practice involves Chelsea and Westminster Hospital in London, whose maternity department states that staff use reflexology and aromatherapy to avoid medical induction of labour. “Treatments are usually non-invasive and rarely cause the unpleasant or long-lasting side effects that can be associated with medication,” it says.
The hospital also offers aromatherapy and acupuncture to relieve pain during labour. Yet the official NHS guidelines body, the National Institute for Health and Care Excellence says staff should not offer or advise such options, although they should support women who choose to use them.
Chelsea and Westminster Hospital did not respond to a request for comment, but a common defence of such practices is that they can help women feel calmer, and are probably harmless. But Dr Hawkins says that in his family’s case, midwives were debating whether to use lavender oil or ylang ylang when they should have been trying to save his baby’s life. “This is another task that distracts midwives from safe care,” he said.
With the Nottingham investigation set to report next year, the spotlight is likely to stay on maternity safety for some time. There are also campaigns for similar inquiries over alleged avoidable deaths at other trusts – including the John Radcliffe Hospital in Oxford, which until recently openly stated staff would refuse any caesareans done for maternal request, a policy that is against Nice guidelines.
Although this ban was rescinded in 2020 after years of local campaigning by patient support group, Birthrights, the fact it ever existed shows that staff there have a dangerous bias, said campaigner Rebecca Matthews.
The hospital was still giving out patient information promoting “normal” birth in 2021, although it declined to say if this was still in use. Yvonne Christley, chief nursing officer for Oxford University Hospitals, said: “The safety of mothers and babies is our top priority, and we aim to support mothers by providing a range of birth choices.”
Whether or not the John Radcliffe campaign succeeds, it is wrong such inquiries have to continue hospital by hospital, say groups such as the Maternity Safety Alliance. They are calling for a public inquiry to look at the entire NHS England maternity system to “understand what’s going wrong and why, and fix it once and for all”.
“It is happening in most maternity units to some degree or another,” said Ms Barley. “It’s pot luck as to who’s on the shift when you go into labour. Natural birth ideology is dangerous and it does kill.”