Protecting human rights in childbirth

Registered Charity Number 1151152

Why we need to have more honest conversations with women about how birth might unfold

The National Maternity and Perinatal Audit (NMPA) clinical report 2019 was published last week and it makes for intriguing reading. For us at Birthrights, the report starts to provide some answers to questions we have been interested in for some time, for instance – is the focus on reducing the stillbirth rate driving up intervention rates, and how do women feel about this? It goes without saying that we have no view on any ‘correct’ rate of birth interventions per se – and interventions can and do save lives – but we are very interested in how far women are making informed choices about the interventions they have.

Downe et al’s systematic review (2018)[1], looking at what women want from childbirth, confirmed that most women want a physiological birth whilst being prepared to accept intervention if necessary. One of the most surprising stats in the NMPA report is that intervention appears to be necessary in up to 90% of cases. Only around 1 in 5 women (23.5% on average) across the country are having an intervention free birth. The fact that our maternity services seem set up to deliver a birth experience that most women would rather avoid is worrying and more research is needed into why this is happening and what the benefits and costs of increased intervention are. (We should also bear in mind that the report relates to births 2-3 years ago (2016-17)).

This is even more concerning when we know from our maternal request caesarean campaign that women who don’t want to take their seemingly low chances of an intervention free birth are often belittled, dismissed and frankly bullied into having a vaginal birth anyway. This holds true even when the reason they want a caesarean is due to the previous birth trauma created by the interventions doled out by the system the last time, and so the cycle continues.

Birthrights has always fought for all women to choose the birth that is right for them – whatever that is, which means we wholeheartedly support the right of women who want an intervention free birth to access maternity services that maximise their chances of this AND the right of women who are making an informed decision to have a caesarean birth to have their choice respected, and everything in between. In trying to explain the changing trends the NMPA report states that: “decision making also reflects shifting perceptions of what constitutes an acceptable level of risk, caseload, cultures and policies in maternity units and individual preferences of clinicians and women.” The fact that women were left lingering at the end of that sentence is telling. There is very little evidence that these trends are being driven by women’s changing preferences, although very few women want to decline intervention that they are being told is in the interests of their baby.

The key is honest conversations with women based on factual, unbiased, and timely information, conveyed in a way that reassures the woman that she is the best person, practically, legally and morally, to decide what is right for her and her unborn child. The UK legal position, reflected in NHS England’s maternity transformation programme and the second version of the Saving Babies’ Lives care bundle, is that women’s autonomy is paramount – she is the primary decision-maker in birth.

Moreover, a whole raft of research shows that women who have a good understanding of what might happen, and feel in control of decisions, are more likely to have a positive birth experience – whatever it involves. At Birthrights, we see far too many stories of women being given partial and/or falsely reassuring information, or sometimes just false information, about their choices. And we also hear shockingly regular accounts of women whose decision is ignored, because it does not align with a health-care practitioner’s well -intentioned but misplaced view that they know best. This is a sure recipe for birth trauma (see Reed et al[2] (2017) for example).

All women are legally entitled to evidence-based, up to date information alongside a full dialogue about all reasonable options with an informed healthcare practitioner, so they can make their own decisions about their birth, as mandated by the Montgomery vs Lanarkshire Supreme Court case.  We look forward to seeing an indicator of valid consent and women’s experience, in the short and longer term, being the core measure of high quality maternity care.

[1] Downe S, Finlayson K, Oladapo OT, Bonet M, Gülmezoglu AM (2018) Correction: What matters to women during childbirth: A systematic qualitative review. PLOS ONE 13(5): e0197791.

[2] Reed, R., Sharman, R. & Inglis, C. 2017. Women’s descriptions of childbirth trauma relating to care provider actions and interactions. BMC Pregnancy and Childbirth, 17, 21.

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