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The Royal College of Midwives (RCM) has published its report on the Re:Birth Project which asked women and birthing people, their families and maternity professionals about the type of language that should be used in conversations and clinical records during labour and birth.
Whilst the project could not produce a standardised vocabulary which met everyone’s preferences, mothers and professionals agreed that clear, factual, language should be used in conversations and clinical records around birth.
Moving away from value-laden, judgmental language about birth
In recent years, the RCM has struggled to provide mothers and the midwives that it represents with a consistent meaning and message related to the term ‘normal birth’.
The RCM points out that in healthcare the word ‘normal’ is used to describe a range of physiological states, such as ‘normal blood pressure’, ‘normal lung function’ or ‘normal fetal growth’. In relation to labour and birth, RCM argues that ‘normal’ is used internationally as a standard way of describing the physiological process of labour and birth. It features in the International Confederation of Midwives’ definition of the midwife’s role, the UK’s Nursing and Midwifery Council’s Standards of Proficiency for Midwives. Legally, clinically and professionally, the need for midwives to ‘optimise normal physiological processes’ is a key aspect of their role.
In the Re:Birth report RCM acknowledge that the term ‘normal’ suggests that births which have involved medical interventions may be viewed as ‘abnormal’, even where there has been a positive outcome for both mother and baby. At its worst, this implies failure for women who give birth by caesarean or with the help of forceps or epidural anaesthesia, and creates a toxic culture in which available, requested, or necessary medical intervention is denied or discouraged.
In August 2017 the RCM finally decided to discontinue its Normal Birth Campaign as part of the Better Births initiative which aimed to improve care for all women during labour and (any kind of) birth. The end of RCM’s Normal Birth Campaign reflected strongly held feelings by women that value-laden and pejorative use of the term normal birth were not appropriate, and references to the campaign were removed from the website as ‘out of date’.
In February 2020, in his call for a maternity safety inquiry, Jeremy Hunt voiced his concerns about whether the safety of mothers and babies was being compromised by a mistaken obsession with ‘normal births’ leading to delays in performing caesarean births.
In February 2022 after hospitals were found to be limiting the number of caesarean sections they performed to meet unsafe targets, NHS maternity leaders wrote a letter to NHS maternity services in England telling them to stop promoting unassisted ‘normal births’. They were reminded that NICE guidance required them to respond to women’s birth choices on an individual basis. Countless inquiries, including the recent Ockenden Review have highlighted the harm that is caused when birth takes place in ideologically driven and judgmental maternity environments.
What is the Re:Birth project?
RCM’s Re:Birth Project was set up in 2020 to try to develop a respectful way of discussing labour and birth that could be shared and understood both by those providing and receiving maternity care.
- The project heard from a total of 7,822 people. This included people from across the UK and 147 from outside the UK.
- 37% were women and people who had been or wanted to become pregnant, given birth, or had supported a family member’s birth. Half of these had given birth within the last five years.
- 48% were midwives, student midwives or maternity support workers.
- 5% were obstetricians or obstetric anaesthetists.
- The other 10% were involved in maternity care or education in other ways, such as doulas, researchers, midwifery lecturers.
- 71% were from a White British or Irish background, and 12% were from minority ethnic communities.
Findings of the Re:Birth consultation
RCM found that safe outcomes for mothers and babies, positive labours and birth experiences and being heard, understood and respected were wanted by all who took part. Many of the women and birthing people were less concerned about how their baby was born, than that their labour and birth were safe. They wanted a positive experience, meaning that they felt safe, listened to, and had autonomy and choice.
Women and other users of the maternity service wanted labour and birth to be described by language that:
- is descriptive and technically accurate;
- is non-judgmental, non-hierarchical, and not value-laden;
- reflects their actual experience, rather than based on assumptions.
Health professionals supported a personalised approach when talking to pregnant women, but also needed consistent, specific terminology to describe different types or methods of birth in medical records, professional conversations, and for the purposes of research, reports and audit. They wanted terms that are:
- clear, descriptive and unambiguous;
- consistently understood between individuals and professional groups;
- specific enough to identify differences in the mode of labour and birth (as an example, just saying ‘vaginal’ is not distinctive enough).
Although a complete set of agreed terms could not be found, RCM were able to identify and recommend some preferred terms for common scenarios to be used when describing the type of labour and birth in medical records, professional conversations, reports and audit. These included:
- Birth – all participants preferred ‘birth’ as the overarching term to describe all births, rather than ‘delivery’.
- Spontaneous vaginal birth - 89% of participants preferred ‘spontaneous vaginal birth’ to describe where labour and birth start spontaneously without induction and progress without the need for medical interventions, such as syntocinon, ventouse or forceps. Additional descriptive words could be added to clarify additional aspects of the labour or birth, such as ‘spontaneous labour followed by a birth with forceps’ or ‘induced labour followed by spontaneous vaginal birth’.
- Birth with forceps - 93% preferred this type of language for a birth where instruments are used. Where instrumental birth followed a spontaneous labour, the description would be ‘a spontaneous labour, followed by birth with forceps/ventouse’.
- Induced and/or augmented labour – 89% preferred this description for a labour using medical intervention. Clarifying adaptations could include, ‘augmented/induced labour with spontaneous vaginal birth’.
- Unplanned caesarean birth - 83% preferred this description (instead of emergency).
- Planned caesarean birth - 99% preferred this description for caesarean which could also be described as ‘elective’, ‘planned’ or ‘prelabour’.
- Caesarean birth – 97% preferred this description as the overarching term for an operative caesarean section. This can also be adapted to ‘planned caesarean birth’ or ‘unplanned caesarean birth’.
Re:Birth – the 5 As.
The Re:Birth Project set out some easy-to-follow steps to support health professionals in conversations about personalised care. They called the guidance The 5As.
- the woman’s previous birth experience;
- if this is her first time;
- if she has previously lost a baby.
- Ask how she would describe her birth, and listen to how she talks about her experiences and preferences.
- Affirm by checking that the description used in the records feels right to her or whether she prefers to describe it another way.
- Avoid making assumptions about her choices, such as what her experience of a caesarean birth might have been.
- Annotate the records with the woman’s own description of her previous birth experience as fully as possible, and her preferred language and terminology.
Women and birthing people have the right to information, choice and safe maternity care
RCM’s Re:Birth report highlights the way in which clear language which is understood by everyone can help women and birthing people feel more supported and make informed decisions about their care. The report also highlights the vital importance of accurate and consistent terminology in all written and verbal communications between the midwives and wider maternity team. This enables correct risk assessment and sharing of important clinical information to provide the mother and baby with safe care.
Non-judgmental language is fundamental to the wellbeing of mothers and their babies during labour and birth. Midwives and mothers must feel safe and supported to make the necessary decisions to provide and receive good maternity care.
Boyes Turner’s birth injury lawyers welcome RCM’s valuable work through the Re:Birth Project and support the participants’ shared vision for all women and birthing people and their babies to receive safe and supported maternity care.
If you or your child have been severely injured as a result of failings in maternity care, you can talk to one of our solicitors, free and confidentially, to find out more about making a claim by contacting us here.
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