The Problem of Normal Birth


Let us get one thing straight: “normal,” as it pertains to childbirth, is problematic. Normal is defined as “regular, usual, typical, ordinary, and conventional; physically and mentally sound; free from any disorder; healthy.”1 It is a word that dichotomizes—if you are not “normal,” then you must be abnormal, atypical, disordered, unhealthy, or irregular—and who wants those labels? Many folks I know want to be “special,” and to what other life situation than pregnancy and childbirth should that label be applied? Most of us in midwifery are taught that every labor and birth is different; therefore, trying to neatly order it into conventional definitions goes against what we believe about the individuality of each woman. Most definitions of normal as they apply to labor and birth include, in part, spontaneous onset at term without medications, intervention, or surgery.2 Yet countless women will bristle when told that their cesarean birth was not normal or that their epidural was less than optimal—see what I mean by problematic? This begs the question, “Why have we made the normal abnormal and the abnormal normal in this perverse way?”3

I propose that “normal” is commonly used by midwives as a way to describe a process that counters the common and escalating interventions in many birth settings. A more fitting term might be “physiologic”— that which reflects the innate capacity of a woman's body to reproduce without intervention—and which most women would be able to achieve when left alone to find their strength, and supported as needed in the process. The term “optimal” acknowledges the best outcome based on the mother's specific needs.4 Soo Downe takes it a step further by describing the salutogenic properties of birth as an event with the capacity to create health.5

I suggest that our culture has situated childbirth fully in risk and normalized childbirth interventions. It is a paradox in which tremendous resources are poured into preventing rare events rather than supporting most women to avail themselves of resources to sustain and improve their health. Fear of birth has become the foundation of child-bearing in US culture. We do not usually fear things that are normal, and therefore childbirth has become culturally pathologic: it is something to be “fixed.” We live in a society where women are likely to have heard only birth stories that include epidurals and cesareans. It is a culture that deifies technology and control, with no room for uncertainty of any kind or for less than perfect outcomes. A recent analysis of top-selling childbirth education books indicates that the language around labor, birth, and cesarean is frightening and abdicates decisions to medicine and institutions.6 Complete faith is placed in the provider to guarantee perfection, and when that falls short (because it will, of course) there is anger and often litigation. We have boxed ourselves into a corner and must, for the health of women and infants, find a way out.

This issue of the Journal of Midwifery'Women's Health (JMWH) tackles the “normal” childbirth debate from multiple perspectives. As the guest editor, I recruited many authors from abroad, particularly in the United Kingdom, where the culture of birth permits approaches different from ours in the United States. This stemmed from my year as a Fulbright Scholar in London, where I was able to explore these issues in-depth, and from multiple interactions with researchers and clinicians exploring the same issues. The articles present research with US midwives discussing what “normal” means to them,7 an explanation of the term “normal” in the Dutch maternity system,8 the introduction of a clinical pathway to foster normal birth in Wales,9 the role of pain in birth,10 reducing risk of perineal trauma by midwives,11 the importance of collaboration,12 outcomes of midwifery-led care,13 and a study on the efforts of two London hospitals' efforts to normalize birth.14 An important new ACNM position statement on the use of nitrous oxide in labor is also included in this issue.15 This self-administered pain relief has been used for years in all birth settings in the United Kingdom and likely contributes to their national low epidural rate of 36%,16 yet it is minimally available to women in the United States.

A common limitation posed about the examination of childbirth in cultures different from the United States is the “apples and oranges” analogy, usually with the statement that we simply cannot compare ourselves to countries with national health systems. I strongly disagree with this viewpoint. My travels have exposed that many in maternity care are facing the same issues—the struggle to support women to birth using their own capacities and the prevailing trends to intervene in the process, even without clear indication. Although national health systems enable collective movements toward change, most progress I have seen is on the local level. It occurs because clinicians and women begin to consider the evidence in a different way and trust that labor and birth processes are purposeful and beneficial for both mothers and infants. It works because clinicians and women talk with one another and learn to trust through those conversations. Mutual trust is a substantial factor in planning and implementing care together and in the prevention of litigation.17

Diony Young, editor of Birth, has also pondered the various definitions of normal birth in the United Kingdom, World Health Organization, and most recently in Canada.18 Interestingly, a search of Web sites of US professional organizations that provide services to child-bearing women reveals no similar statements about normal birth—not even those representing the profession of midwifery. I pondered this with several colleagues and we wondered if the reason could be that midwives have such a strong sense of birth as a normal event they just do not see the need for a formalized statement. For example, the American College of Nurse-Midwives (ACNM) philosophy states, “We honor the normalcy of women's lifecycle events. We believe in watchful waiting and non-intervention in normal processes.”19 But is it time for a formal statement? Childbirth Connection, the strongest childbirth advocacy group in the United States, recently released a “Blueprint for Action” to transform and create high quality maternity care.20 Among their many recommendations was a call for enhanced decision-making and consumer choice including the promotion of a cultural shift in attitudes toward childbearing. Regardless of the problematic language of “normal,” I wonder if we might foster this cultural shift if our professional organizations did come together to publicly commit to the importance of physiologic birth in maternal and infant health? This is especially important in light of the March 2010 National Institutes of Health Consensus Statement on Vaginal Birth after Cesarean.21

In closing, since 2001 I have had the honor of presenting my research at the United Kingdom Research Conferences on Normal Birth—a gathering of midwives, clinicians, and researchers who ponder these issues together.22,23 During those meetings, I have debated with a vast array of people with great minds, but none more special than Tricia Anderson. Many in the United States have never heard of this midwife, and that is a shame. She was the coeditor of The Practising Midwife, a very practical journal published in the United Kingdom. Tricia directly confronted the “normal” debate, and her writing resonated with midwives and childbearing women. In the years before her untimely death, she was conducting critical research that integrated “trust” and the powerful properties of endogenous oxytocin. Nicky Leap described her as a midwife and researcher who fostered a curiosity about childbirth and encouraged her readers to think about the transformational potential of birth. We hope this issue of JMWH will do the same for you. I learned much about birth and life from Tricia Anderson and dedicate this issue to her articulate, feminist, courageous, and gently fierce spirit.