What is Normal Childbirth and Do We Need More Statements About It?

Natural childbirth and normal childbirth were ingrained as real events in my life. So, although the topic has been around and debated for over 70 years, I cannot escape commenting on the recently published “Joint Policy Statement of Normal Childbirth”(1) by Canadian maternity organizations. After all, my mother in New Zealand was one of the first to use the “natural childbirth” method espoused by Grantly Dick Read (2) when my twin sister and I were born, followed by three siblings, who included another pair of twins born at home. Then, over 30 years later, my two children were born by natural childbirth, although then it was called “prepared childbirth,” one in a hospital in Rochester, New York, and the other in a 12-bed hospital in New Zealand. A generation later it was the turn of my daughter in the early 2000s, whose two children were also born by natural childbirth, the first in a U.S. hospital birth center and the second at home. It is easy enough to describe the components of those natural and normal births—physiological labor and delivery, no drugs or medical interventions, a spontaneous delivery, no episiotomy, minimal mother-baby separation, and early and exclusive breastfeeding. But today, in most Western countries, having this type of “natural childbirth” is an unusual event in a hospital, and most likely to occur with a midwife at home or in a free-standing birth center. Judged by today’s standards of maternity care, including the recent policy statements (1,3,4), my mother’s two sets of twin births with breech presentations for the first twin would be considered anything but “normal.” But, for her, they were both “natural” and “normal.” Two well-known statements on “normal childbirth” came from the World Health Organization (3) and the Maternity Care Working Party, composed of the Royal College of Midwives, Royal College of Obstetricians and Gynaecologists, and National Childbirth Trust (4). The new statement from Canada (1) was developed by several provider groups—the Society of Obstetricians and Gynaecologists of Canada (SOGC), Association of Women’s Health, Obstetric and Neonatal Nurses of Canada, Canadian Association of Midwives, College of Family Physicians of Canada, and Society of Rural Physicians of Canada. In addition, over the years consumer childbirth groups in the United States, the United Kingdom, and other countries have developed their own statements on “normal childbirth.” So, one might ask, is another policy statement on “normal childbirth” really needed? Does the Canadian consensus statement add useful new and important information? Before looking at specifics, a few points should be mentioned. As the WHO statement notes, despite much debate and research, “the concept of ‘normality’ in labour and delivery is not standardized or universal” (3, p.1). That is still true today. In the last three decades, with the aim of improving outcomes for mothers and babies, a vast range of practices have been introduced to start, accelerate, monitor, and numb the physiological process of labor, thereby making the concept and practice of “normal childbirth” an ever-changing and ever-expanding process. In addition, the commonly cited and widespread notion that “childbirth can only be declared normal in retrospect” has led to all births being considered and managed as if they were high risk. If we agree with anthropologist Brigitte Jordan that pregnancy and birth are both physiologically and culturally defined, we have to concur that “A society’s way of conceptualizing birth constitutes the single most powerful indicator of the general shape of its birthing system” (5, p 48). And, in Canada and the United States that birthing system is more likely to be managed as a medical and technological event by physicians rather than guided as a physiological and social experience by midwives. In light of these points, how do the WHO, British, and Canadian statements define “normal childbirth”? To begin, each describes normal birth in its simplest and lowest level of risk—as a physiological event without medical intervention. The WHO’s definition (3, p 4): We define normal birth as: spontaneous in onset, low-risk at the start of labour and remaining so throughout labour and delivery. The infant is born spontaneously in the vertex position between 37 and 42 completed weeks of pregnancy. After birth mother and baby are in good condition.…In normal birth there should be a valid reason to interfere with the natural process. The British consensus statement’s definition (4, p 3): The Information Centre definition ‘normal delivery’ is a measurement of the process of labour and not outcomes. The “normal delivery” group includes women whose labour starts spontaneously, progresses spontaneously without drugs, and who give birth spontaneously. The Canadian joint policy statement’s definition (1, p 1163) closely follows that of the WHO: A normal birth is spontaneous in onset, is low-risk at the start of labour and remains so throughout labour and birth. The infant is born spontaneously in vertex position between 37 and 42+0 completed weeks of pregnancy. Normal birth includes the opportunity for skin-to-skin holding and breastfeeding in the first hour after birth. The WHO statement’s focus is on low-risk births only, with evidence-based care, and if a complication occurs, it recommends appropriate referral to a higher level of care (3). With an apparent intent to facilitate collection of birth statistics for audit, the British and Canadian statements next introduce a medical definition of “normal,” listing the criteria that apply to those “normal birth” women who experience complications or who may require “evidence-based intervention in appropriate circumstances to facilitate labour progress and normal vaginal delivery” (1, p 1163). “Normal birth” is here defined as a medically managed event that can include augmentation of labor; artificial rupture of membranes; pharmacological pain relief (nitrous oxide, opioids); and managed third stage of labor. The statements do have a few differences. For “normal birth” the Canadians also include intermittent fetal auscultation and epidural analgesia, but exclude continuous electronic fetal monitoring for low-risk birth; on the other hand, the British include electronic fetal monitoring, but exclude epidural analgesia. Both statements are in agreement to exclude from the “normal birth” group women who experience induction of labor, spinal analgesia, general anesthesia, forceps or ventouse, cesarean section, and episiotomy. The Canadian statement also excludes fetal malpresentation from this “normal birth” group. Why, I wonder, does the Canadian statement consider epidurals to be an appropriate intervention for “normal birth” in contrast to the British statement? This disagreement may be based on differences in epidural availability or use between North America and the United Kingdom or may reflect the increasing prevalence and acceptance of this method of pain relief in North America. Strangely, too, when specifying those procedures that “increase the likelihood of medical interventions (and) should be avoided where possible” (4, p 1), the British statement points to continuous electronic fetal monitoring and epidurals in labor, yet includes use of the former in “normal birth” and excludes the latter. The really positive and important element for “normal birth” contained in the three statements is the strong endorsement and promotion of psychological and social aspects of labor and birth, including respectful care, antenatal education, support in labor, informed choice and consent, supportive environment, nonpharmacological methods of pain relief, evidence-based information and practice, avoidance of routine interventions, mother-baby togetherness, availability of midwives for one-to-one care (3,4), and choice of birth place including home birth (3,4). “Natural childbirth,” both the term and the practice, is given fresh prominence by the Canadians. It is gratifying to read that low-risk pregnant women “should be given information, encouragement, and support to experience a natural childbirth,” and that care providers “should be given information, encouragement, and support to facilitate a natural childbirth” (1, p 1164). Similarly, the British statement also endorsed education and training “of midwives to support women who wish to give birth without technological interventions” (4, p 2). (That sounds like “natural childbirth” to me.) It was equally gratifying to read in the Canadian statement that “vaginal birth following a normal pregnancy is safer for mother and child than a Caesarean section” and that “a Caesarean section should not be offered to a pregnant woman when there is no obstetrical indication” (1, p 1164). Now, as cesarean delivery rates escalate alarmingly all over the world, perhaps it really is the time for a rebirth of “natural childbirth.” Do we need more statements about “normal childbirth”? Initially, I thought not—that the WHO and British statements were enough. The Canadian statement does underline much that has been stated and recommended before, but it adds other pieces in an ever-expanding view of “normal childbirth.” Each country and region has different health systems, resources, and gaps in services that will demand both universal and culture-specific solutions. The WHO statement stands alone in identifying types of birth caregivers (obstetrician-gynecologists, midwives, general practitioners, and traditional birth attendants) and their roles in normal birth (3). The British statement names “midwives” and describes their role as primary caregivers in normal birth, with “consultant obstetricians” as backup; “general practitioners” are not mentioned (4). The Canadian statement refers only to generic “maternity care providers” and “health care professionals,” but does not mention “midwives,”“family physicians,” or “obstetrician-gynecologists,” or describe their roles in normal birth (1). It should. The Canadian statement recommends developing its own national practice guidelines on normal childbirth. This positive endeavor is welcome. When it does so, I urge the SOGC and its partners to follow the example of the British Maternity Care Working Party (4) and invite consumer childbirth and women’s groups to join them in planning these guidelines, since their input was missing from the “Joint Policy on Normal Childbirth”(1). Clearly, “normal” has a different meaning in different countries. The dominant cultural definition and experience of childbirth in North America and elsewhere are widely recognized to be medical and technological in both philosophy and practice (3,5), and as evidenced from the medical inclusion criteria for “normal birth” listed in the British and Canadian statements (1,4). As long as birthing systems continue to evolve in this direction, definition of “normal” will evolve to keep up. Provider and consumer groups will have to continue to make their voices heard in support of natural childbirth and, hopefully, a more normal “normal childbirth.”

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