Supporting Physiological Labour and Childbirth in Modern Maternity Services

There is global debate about the causes and potential long-term public health harms of population rates of caesarean section above those shown to be beneficial [1]. Rising rates of freebirthing in high income countries are also a concern. Some women choose elective caesarean section or freebirth because they do not trust local maternity services to support them when they are hoping to have a safe, positive physiological labour and birth [2]. Curiously, there is very little focus on how to increase the chance of this outcome for those who value it. The international review of guidelines for normal labour and childbirth published in this volume found that only three of the 25 included documents were rated highly on both quality assessment tools used [3]. However, there was agreement across most guidelines on a range of effective procedures and support techniques. These provide a starting point for rebalancing intrapartum care: but, while necessary, they may not be sufficient. Guidelines are, in theory, a driver of high quality health and social care, but their value in practice depends on a range of conditions. There must be underpinning evidence of sufficient quality and breadth. The recommendations must be acceptable to those providing and those receiving care. They must be feasible to implement, sustainable, and affordable. There should be no foreseeable unintended consequences in terms of inequity, inaccessibility, or down-stream adverse effects. They need to be flexibly drafted and applied, to take account of individual circumstances, values, and decisions, so that the label ‘care outside of guidelines’ is only required in very few unusual cases. Importantly, there needs to be an organisational will to apply them in full, rather than cherry picking aspects that happen to meet existing practice and resources, and that are non-controversial locally. For physiological labour and birth, this is where problems arise. There are still significant research gaps. Intrapartum physiology and psychology are dynamic and highly individual. If organisations and governance systems treat labour and birth guidelines as standardised rules that must be applied to everyone, regardless of their physiology, values and choices, staff will not risk organisational and peer opprobrium by personalising care. If staff in all settings are not skilled, confident and competent in supporting labour and birth progress at a pace that is safe and relevant to the individual [4], they are likely to default to interventions to ensure that birth happens within a standardised timescale. If safe out of hospital options are not available, or if staffing models lead to frequent diverts from birth centres, or refusal to send midwives to home births, women will not have access to places where they are more likely to have a physiological labour and birth. Service user faith in the maternity system will further decline, resulting in increased rates of maternal choice for elective CS or freebirth. Rebuilding trust in maternity services cannot happen without the political, organisational and financial will to make best practice in physiological labour and birth available everywhere, for everyone with this preference. Hernandez-Martinez and colleagues have provided a roadmap. Now maternity services need to use it. S.D. devised and wrote the commentary. The author has nothing to report. The author has nothing to report. The author has nothing to report. S.D. has been a Technical Advisor to the World Health Organisation for a range of their guidelines, including the Intrapartum Care for a Positive Childbirth Experience guideline cited in the associated review. She also led the qualitative evidence synthesis reviews for that guideline. This is a mini-commentary—there are no underlying data to share.