The Ockenden Report: are we making natural birth a scapegoat?

“ Three hundred babies lost to a fixation on natural births” screamed the Sunday Times headline in its coverage of the Ockenden Report into excess maternal and infant deaths at Shrewsbury and Telford Hospitals. The focus on “ natural births” as being the root of all problems echoes the response to the Morecambe Bay investigation into twelve deaths at Furness General Hospital in the early 2000s and the statements earlier this year from the Royal College of Midwives backing away from any policy of supporting “ normal” birth.

Normal? Natural? What do these words mean? And why are they used interchangeably?

I have been teaching antenatal classes and supporting birthing women for nearly twenty years, and I have yet to see any evidence of this “ fixation on natural births” in our maternity wards. Instead I hear, over and over again, women telling me that they have been advised to have their labour brought on — induced — for all kinds of reasons.  

The advice often sounds more like a command. The women are supposed to be making an “ informed choice” and to have autonomy, but it doesn ’ t always feel like that.

“ We ’ re booking your induction for the 12th, when you ’ ll be at 41 weeks.”

“ Your baby is too big… too small…  too quiet … you are too old… too fat… too thin. So we ’ re going to induce you.”  

The Ockenden Report found, we are told, that in Shrewsbury and Telford “ mothers were routinely overmedicated with drugs to bring on contractions to lead to vaginal birth”. This is not natural birth. Inducing and augmenting labour are interventions — big, serious interventions. The intervention rates in these hospitals were incredibly high. Why is “ natural birth” being blamed?  

The answer seems to be that doctors at these hospitals apparently believed induction of labour and the use of synthetic oxytocin — Syntocinon — to be “ natural” because its aim is a vaginal birth. This is also often referred to, rather carelessly, as a “ normal” birth.

Syntocinon is a very powerful drug and far from “ natural”. Yet its use is certainly becoming normal. Nearly a third of all births in the UK are now induced, and the overall total climbs year by year.  

For decades it has been known that induction of labour increases the chance of an emergency caesarean . Much of the evidence suggests that for first time mothers, that chance is doubled .  

In the two NHS trusts where most of my clients give birth, 13-16% of births are planned caesareans (most commonly at the urging of medical professionals — the idea that many women are “ too posh to push” is insulting) and a staggering 18-19% are emergency caesareans. These figures are comparable with trusts all over the country .

The publicly available data does not reveal how many of these emergency caesareans followed induction of labour, which would be helpful information for women. But overall the picture of maternity care is not one of midwives and even doctors determined to avoid interventions at all costs. Far from it: the rates of induction and emergency caesareans have both been steadily rising for the whole of this century so far.

Some of those emergency — or, more accurately, unplanned — caesareans happen because the woman ’ s body is refusing to respond to being prodded into birth days, even weeks before it is ready. “ Failure to progress” or “ failed induction”, it will say on her maternity notes, for ever more defining her mothering journey as beginning with failure.

And many of these caesareans happen because Syntocinon has a nasty tendency to cause contractions to come too hard, too fast, too close together. This means that the baby can ’ t recover in between contractions, as he or she would with a spontaneous (i.e. natural) labour.

Monitoring indicates the baby is losing oxygen as a result and, if not delivered quickly, may suffer brain damage. And sometimes, as tragically shown at Telford and Shrewsbury, it ’ s too late.

Because the process is so risky, policy dictates that women are continuously monitored. In the NHS this means relying on technology from the 1970s: clumsy, bulky transponders, held in place by elastic belts that slip and slide whenever the poor woman moves. She is in excessive pain yet is in effect being told, like Lady Curzon in the marriage bed, that “ ladies do not move”.  

I find it extraordinary that birthing women are still being strapped to outdated monitoring machines when in every other area of medicine, modern technology is embraced for the benefit of the patient ’ s comfort.

In such a situation, any chance of an active labour and birth in which she can mobilise the natural, indeed remarkable, flexibility of her pelvis to encourage her baby down goes out of the window. She turns thankfully to the epidural, which brings its own downsides, notably an increased risk of a forceps or ventouse delivery .  

And if labour stalls? Whack up the synto and, if things go wrong, blame “ natural birth”.

In a country blessed with well-trained autonomous midwives, we fail to recognise the evil of making them work twelve-hour shifts, sometimes unable to eat or even go to the toilet. A midwife makes a wrong judgement call? Blame “ natural birth”.

A woman wants a home birth? Send her a midwife who has had scant experience of home birth, because hardly any women in her area have them — and if she makes a poor judgement, don ’ t blame the system. Blame “ natural birth”.

Time and again it has been shown that continuity of care improves outcomes. In 2018 we were promised that with the help of funding and training more midwives, by this year women would be seen by a dedicated midwife throughout their pregnancy.  

Yet I still hear tale after tale of rushed midwife appointments, notes going missing, phone calls and texts unanswered. My clients from abroad are invariably surprised by how few antenatal appointments they are offered compared with other countries. Instead of increasing antenatal care, giving midwives the space and time to really look at their patients, we blame our stubbornly unmoving rate of stillbirths on “ natural birth fanatics”.

Throughout the reporting of Ockenden, I find not one national newspaper journalist prepared to unpick the evidence supporting the reliance on induction of labour. Or the poor evidence that continuous monitoring actually does any good , for that matter. Instead, highly emotive quotes are highlighted which will confuse and terrify any woman approaching childbirth.

One traumatised, grieving mother was quoted describing midwife-led units as “ death traps” because her baby died in one. Yes, this was terrible. No, it should not have happened. But birth centres, as they are more usually called, don ’ t normally do medical inductions and they are not death traps. The huge Birth Place Study of 2011-12 showed that birth outcomes for low risk women in midwife led units, especially those situated inside a hospital (and thus a quick trolley-push from the operating theatre) are better than those in obstetric units (the doctor-led labour ward, to you and me).  

The same study also found that home birth was safer for low risk women who had birthed before. But the Birth Place Study does not fit the narrative of evil, witch-like midwives glorying in forcing women to certain death, so it is little mentioned.

If there is a bias among obstetricians, it is definitely towards induction “ just in case” — and, if truth be told, against trusting a woman ’ s body to work well. In 2019 the British Journal of Obstetrics and Gynaecology published a free-to-access article arguing that all women should be induced at term. The lead author was employed by a major pharmaceutical company which manufactures induction drugs, it turned out. (Another article which put an alternative view was initially kept out of sight, behind the journal ’ s paywall, until health professionals protested.)

An induced labour is, as the NHS ’ s own guidelines warn, likely to be longer, more painful and to bring other interventions in its train. There are often good reasons for it, and in my years of listening to women and their partners tell me their birth stories, I ’ ve heard a few happy induction stories (many more unhappy ones, I ’ m afraid). There are also very good reasons for advising a woman to have a caesarean birth.

We are lucky to have these interventions at hand. But please, can we try to separate what is “ normal” from what is “ natural” and recognise that the failings at Shrewsbury and Telford hospitals were as much connected with a dogged belief in interventions as with anything else.

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