Changing Childbirth 20 years on

Baroness Julia Cumberledge’s 1993 report, Changing Childbirth, (sadly unavailable online) was a landmark in UK maternity care; a key pushback by the advocates of natural childbirth against excessive interventionism. Powerful and timely, it upset the obstetric establishment.

At a 20-year anniversary meeting at the Royal College of Obstetricans and Gynaecologists (RCOG) last week many of the original Expert Maternity Group recalled the hostility of the RCOG nabobs who, having largely ignored the reports preparation, objected to its conclusions. Someone alleged that Mary Anderson’s later bid for the college presidency failed because, as the obstetrician on the Expert Maternity Group she had been perceived as having “gone native”.

But not all obstetricians were hostile, and many recommendations – women carrying their own records, keeping them informed, treating them with respect – were already well underway. Changing Childbirth just gave a crucial push for this sort of humanisation of maternity care.

But reversing interventionism? The report recommended increasing midwife numbers so women knew the person who cared for them in labour, and stopping the closure of smaller units?  Rather than directly recommending births at home or in midwife-led units (MLUs), the report said that women should have a choice, and presumably their choice would result in more such deliveries. The hope was to reverse the rise in Caesareans, inductions, electronic fetal monitoring, epidurals, and instrumental deliveries? But did the rates of any of these fall? Have normal births risen in the last 20 years?

The answer of course is no, no and no again!  The tide of obstetric intervention rolled right over Changing Childbirth. Hospitals continued to centralise, instead of midwives it was medical staff numbers that increased, and hardly anyone now knows the midwife who delivers them. Sure, home birth rates rose by a percentage point or so, and some new MLUs opened, albeit mostly alongside consultant ones. But the home birth rate was already rising slightly in 1993, and free-standing MLUs closed as fast as new ones opened. (Examples here and here.)

There were many reasons. Litigation had already been rising in 1993, as parents became less forgiving of bad outcomes. Much of the new interventionism followed efforts to make birth safer, or at least mount a successful defence against the lawyers. The increase in consultant obstetrician numbers was intended  to ensure that more of them spent time on the labour ward, and it partly succeeded. In service training, audit and governance got tighter for good reasons. Emergency care outside the security of hospital shift patterns, and continuity of midwife care are both difficult to reconcile with modern demands for a reasonable work/life balance. And perhaps, whisper it softly, perhaps the desire for natural birth is just a middle class fad!

Or maybe Cumberledge was ahead of its time – 20 years ago there was little evidence about the safety of home or MLU births. But in 2011 the Birthplace Study (click here) showed that both were safe for many women; they may even save money by reducing interventions. It’s early days, but some recent free-standing MLUs, such as those in Huddersfield and Burnley Blackburn, have got off to a good start.

I wonder. Sceptics about the real unmet demand for natural childbirth still report that parents seem to care more about safety and good pain control. But they’re mostly male obstetricians. What do they know?

Jim Thornton