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‘This book centres on seminal research undertaken to examine the complex,
multifactorial, organisational, professional and interpersonal elements that shape
and inuence midwives’ behaviour, role, expectations and clinical work. It oers
a unique and poignant insight into the tensions, challenges and opportunities
that many working midwives encounter as they navigate their way through an
increasing polarisation between the alignment of a professional mandate anchored
in a social model of enablement and advocacy for women and their families and
employer expectations and constraints. A shortfall of skilled midwives is not
unique to the UK. However, this is not occurring solely because of retirement;
attrition is a major issue, be it midwives switching to work part-time or leaving
midwifery because they do not receive the support, respect or resources to enable
them to provide personalised skilled care. This research presents an important
resource for all maternity stakeholders to consider and reect upon when shaping
humane, dynamic, supporting organisations that enable midwives to thrive’.
Dr Ethel Burns, Senior Lecturer Midwifery,
Oxford Brookes University
‘This is such an important book addressing the ethical, cultural, and political
challenges faced by midwives supporting physiological birth choices and women
navigating maternity care in the current climate. The author is extremely knowl-
edgeable on the eld of personalised care and the complexities associated with
its implementation in the real world. This is an essential book to understand
how we got here in the rst place and how we can move on, putting women
and birthing people at the helm and facilitate whatever choice they make, in any
setting they choose’.
Lia Brigante, Midwife, RM, MSc
‘Claire Feeley’s book comes at a critical time for midwifery. Centring the ethical
concept of bodily autonomy, so intrinsic to midwifery practice, she identies
the tensions that arise for midwives, who are philosophically bound to be ‘with-
woman’, when women make decisions that do not comply with recommended
guidelines. That such a book needed to be written is already an indictment of
maternity systems worldwide and their inability to provide individualised care.
As reports of obstetric violence and birth trauma rise, this book provides an
important contribution in its incisive discussion of the current pressures, but its
real eect is in the oering of a solution – where midwives’ professional respon-
sibility to provide safe care can comfortably co-exist with women’s choices,
regardless of what that choice might be. A must-read for anyone interested in the
culture, ethics, or practice of childbirth’.
Dr Elizabeth Newnham, Senior Lecturer,
University of Newcastle, Australia
‘I propose that all those with an interest in maternity services should read and
be guided by the ndings and proposals in this book. We must learn from what
works – meeting the needs and facilitating choice is possible when there is a
culture of mutual respect, support and compassionate leadership. The text oers
evidence-based practical solutions in an engaging and clear format – an absolute
gem and gives me hope for the future’.
Sheena Byrom, OBE, Midwife, Co-Founder
ALL4Maternity
‘Just nished reading your book, it is so good, so important, and so well written!
I have felt rather despondent about midwifery and maternity services in the UK
since I returned from practicing in New Zealand in 2012, it captures much of
what I have been concerned about and I realise that part of me had ‘given up
the ght’, as it has felt too big a challenge. But, reading this reminds me that it
is too important to give up on… Congratulations on this work, thank you for
articulating it so well’.
Dr Tomasina Stacey, Midwife, Senior Lecturer
King’s College London
‘This timely and articulate book urges us to think more deeply about the
socio-cultural and political inuences that shape midwives’ practice and the care
that they are able to oer to birthing women and people. Drawing on her origi-
nal feminist narrative inquiry research, Claire Feeley vividly describes how UK
midwives responded to women’s requests for ‘out of guidelines’ birth choices
and explores what can be learned from their responses. Using midwives’ rst-
hand accounts of the challenges and enablers they experienced, a compelling
argument is created: that compassionate leadership, trust in sta ability and in
maternal autonomy are critical for high quality, respectful and culturally safe
maternity services. An essential and thought-provoking read for everyone want-
ing to understand current debates in maternity care’.
Billie Hunter, CBE, FRCM PhD, BNurs, RM, RN
Emerita Professor. Cardi University
‘Claires passion for supporting physiological birth is infectious and her work
incorporates a holistic approach to midwifery care. This book will provide the
evidence base for midwives in practice to centre the needs and wishes of women
and enable them to support physiology and individualised care’.
Cheryl Samuels, ‘Holistic Midwife’ and Lecturer, University
of Suolk
‘This brilliant book is commanding and provocative in its argument for a truly
equitable maternity service. From the vantage point of how midwives support
physiological birth, Claire Feeley makes visible fundamental tensions in mater-
nity care concerning birthing women and peoples’ choices. Feeley’s assessment
of why ‘out of guidelines’ birth choices have come to be viewed as so prob-
lematic provides a comprehensive and considered account of the socio-cultural-
political landscape of present-day services where medicalisation, standardisation,
risk, governance, and litigation issues are the norm. Drawing on the views and
experiences of midwives employed in the UK’s National Health Service, this
book shines a light on the barriers women and birthing people can face when
asserting their autonomy, and also why midwives leave. Feeley is visionary in her
conception of collective responsibility and the centrality of organisational cul-
ture and system-wide solutions towards more equitable maternity services. This
book is essential reading’.
Dr Carol Kingdon, Reader in Medical Sociology,
University of Central Lancashire, and Hon. Research Associate,
University of Liverpool and Liverpool Women’s NHS
Foundation Trust
SUPPORTING PHYSIOLOGICAL BIRTH
CHOICES IN MIDWIFERY PRACTICE
Highlighting the experiences of midwives who provide care to women opting
outside of guidelines in the pursuit of physiological birth, Claire Feeley looks at
the impact on midwives themselves, and explores how teams and organisations
support or discourage women’s birth choices.
This book investigates the processes, experiences and sociocultural-politi-
cal inuences upon midwives who support women’s alternative birthing choice
and argues for a shift in perspective from notions of an individual’s professional
responsibility to deliver woman-centred care, to a broader, collective responsi-
bility. The book begins by contextualising the importance of quality midwifery
care with an exploration of the current debates to demonstrate how hegemonic
birth discourse and maternity practices have detrimentally aected physiological
birth rates, and the wellbeing of women who opt outside of maternity guide-
lines. It provides real life examples of how midwives can facilitate a range of
birthing decisions within mainstream midwifery services. Moreover, an explo-
ration of midwives’ experiences of delivering such care is presented, revealing
deeply polarised accounts from moral injury to job fullment. The polarised
accounts are then presented within a new model to explore how a midwife’s
socio- political working context can signicantly mediate or exacerbate the vul-
nerability, conict and stigmatisation that they may experience as a result of
supporting alternative birth choices. Finally, this book explores the implications
of the ndings, looking at how team and organisational culture can be developed
to better support women and midwives, making recommendations for a systems
approach to improving maternity services.
Discussing the invisible nature of midwifery work, what it means to deliver
woman-centred care, and the challenges and benets of doing so, this is a
thought-provoking read for all midwives and future midwives. It is also an
important contribution to interprofessional concerns around workforce devel-
opment, sustainability, moral distress and compassion in health and social care.
Claire Feeley is a clinical midwife and researcher with over 13 years’ experience
in maternal, perinatal and infant health. Formerly the editor-in-chief of The
Practising Midwife, Dr Feeley is now a lecturer and researcher at King’s College
London.
SUPPORTING
PHYSIOLOGICAL BIRTH
CHOICES IN MIDWIFERY
PRACTICE
The Role of Workplace
Culture, Politics and Ethics
Claire Feeley
Cover image: © Getty Images
First published 2023
by Routledge
4 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
and by Routledge
605 Third Avenue, New York, NY 10158
Routledge is an impr int of the Taylor & Francis Group, an informa business
© 2023 Claire Feeley
The right of Claire Feeley to be identied as author of this work has
been asserted in accordance with sections 77 and 78 of the Copyright,
Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced
or utilised in any for m or by any electronic, mechanical, or other
means, now known or hereafter invented, including photocopying and
recording, or in any information storage or retrieval system, without
permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks
or registered trademarks, and are used only for identication and
explanation without intent to infringe.
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library
ISBN: 978-1-032-20831-2 (hbk)
ISBN: 978-1-032-20827-5 (pbk)
ISBN: 978-1-003-26544 -3 (ebk)
DOI: 10.4324/9781003265443
Typeset in Bembo
by codeMantra
For James, my darling son, what a wild ride we have had so far!
Thank you for being you, I love you.
CONTENTS
List of gures xv
List of tables xvii
Foreword xix
Preface xxiii
Glossary xxvii
1 Introduction 1
Childbirth and midwifery: Setting the scene 1
‘Alternative’ physiological birth: Autonomy, choice and tensions 4
Independent and employed midwives 7
The research 8
Conclusion 10
References 14
2 Rhetoric vs. reality: the power of hegemonic birth practices 22
Rhetoric vs. reality 22
Understanding the why: Sociocultural-political drivers 25
Medicalisation 25
Institutionalised birth 28
Risk, governance, litigation and fearful defensive practice 31
The politics of evidence-based medicine 33
Guideline-centred care, the crux of this research 36
References 39
xii Contents
3 Counter discourses: resistance in action 49
Cultural tensions: The ‘good’ mother 49
Ethical tensions for, and between midwives 51
Resisting the status quo 52
Responsive midwifery 54
Safety reconstructed through relationships 56
Tools not rules 58
Ethical competence 61
What has been achieved, what is possible? 63
References 64
4 Moral compromise and distress: Midwives’ invisible wounds 70
Emotion stories: Moral distress and the workplace 70
Stories of distress 72
Stories of feeling torn 72
Stories of battle 76
Stories of reproach, recrimination or vilication 80
Unmet needs, wounded midwives 83
References 85
5 Psychologically safe work environments: creating the
conditions for fullment 87
Emotion stories: Psychologically safe, enabling environments 87
Stories of transition 89
Stories of fullment 92
Stories of normalised practice 93
Stories of togetherness 95
Stories of the sublime 97
Meeting the needs of midwives, meeting the needs of women 100
References 101
6 Stigmatised to normalised practice: a new lens 104
Normal/stigma, deviance/positive deviance 104
‘Stigmatised to normalised practice’ – A theoretical model 107
Stigmatised practice 107
Deviant practice [lone ranger] 110
Optimal deviancy [protective teams] 111
Optimal deviancy [respected individually] 113
Sub-optimal normalised practice [positive deviants] 114
Optimal normalised practice 116
A new perspective 117
References 118
Contents xiii
7 Shifting the lens: towards a collective responsibility 122
Constraints 123
Negative organisational culture 123
Disparities of philosophies 125
Protective factors 126
Supportive like-minded teams 127
Dierent, not deviant 127
Enablers 128
Positive organisational culture 128
Transformational, compassionate, collective leadership 129
Skilled heartfelt practice 131
Enabling work environments, enabling birth choices 132
References 134
8 Appendices 139
Appendix 1 139
Appendix 2 141
Acronyms 143
Appendix 3 143
Index 147
FIGURES
6.1 Theoretical model: stigmatised to normalised practice 108
7.1 Constraints, protective factors, and enablers 123
TABLES
A.1 Participant demographics 139
A.2 Range of alternative birthing decisions reported by study
participants with acronym key 141
A.3 Typology of the midwives’ experiences within their micro,
meso, and macro workplace contexts 144
FOREWORD
I have been lucky to be part of Claire’s journey over the last decade – rst,
as her master’s dissertation supervisor where she explored women’s reasons for
freebirthing and then as the Director of Studies for her PhD, which is the focus
here. This book is centred on choice for a specic type of birth – a vaginal phys-
iological birth. Overall, choice is a contested term, as, on the one hand, it sug-
gests equity in that there are options that all can choose from, people have free
choice to decide their preferred option and for what they choose to be a viable
option. However, often the reality in a maternity context, choices that women
and birthing people can make are inexplicably linked to risk, fear and litigation.
As soon as there is a potential for perceived risk, then ‘choices’ can become
rhetorical. In this book, Claire questions the constructs of the risk discourse
and ‘guideline-centred care’ as an enforcement tool– this is whereby women’s
choices can be shaped by standardisation, institutionalisation and risk. While
bound within a tautology of guidelines needing to be used as guidelines, Claire’s
research stems from the knowledge that these are often used as clinical ‘rules’ to
restrict women and birthing peoples’ bodily autonomy in how and where they
give birth. This can be particularly apparent for a physiological birth, particularly
when the birth is perceived as having higher risks, and where healthcare profes-
sionals have potentially less input and control over what happens.
While risk-based care has been the focus of a wealth of literature, Claire’s aim
was to explore a unique perspective of how midwives and maternity structures
enable choice for a physiological birth when the women’s and birthing peo-
ple’s history or physiological signs indicate otherwise – referred to as an ‘out of
guidelines’ birth or, as Claire’s refers, an alternative physiological birth. She also
focused her research on midwives who were employed by the NHS to under-
stand how choice can be enabled when operating within its arguably more rigid
and institutional-based connes. Claire’s work beautifully captures stories from
xx Foreword
45 midwives who work across the UK and uses a theoretical model to depict the
polarised accounts of how midwives can (or are restricted to) support an alter-
native physiological birth. At one end of the continuum, she describes emotive
accounts of midwives who face stigma, and moral distress when deviating from
‘usual care’ to occasions of midwives having to ‘bend the rules’ to operate outside
of expected norms, through to accounts of mutually supportive and multidisci-
plinary collaboration when more authentic forms of choice are enacted. This is
a book that speaks of hope, resilience and courage, and provides practical strat-
egies and approaches from an individual, team and organisational perspective. It
reects a salutogenic approach that illuminates not only the challenges that can
be faced but also the occasions of when, how and by whom alternative physiolog-
ical birth choices can be enabled. Giving birth is one of the most signicant and
important life transitions – this book emulates the values of essential maternity
care by oering ways to enable and optimise safe and personalised care, and to
ensure the physical and psychological wellbeing of all.
Professor Gill Thomson, University of Central Lancashire
There has been signicant debate about the current state of midwifery around
the world. Stang shortages, moral distress and a rising exodus of sta character-
ise the debate. Reasons proposed for sta attrition have included poor life-work
balance, overwork, incapacity to do the kind of midwifery midwives want to do,
or to ensure safety for women, birthing people and babies, neoliberalist consum-
erism, individualism and/or technocracy. However, in all this theoretical debate,
the voice of midwives themselves has been relatively silent.
In this book, Claire Feeley has unpacked some of the most deeply felt stories
of midwives working at the edges of standard maternity care through the lens
of so-called ‘out of guidelines’ situations. This focus provides new insights into
all the theories listed above, through the perspective of ‘emotionality’ and psy-
chological safety. The stories of the included midwives illustrate the hypocrisy
of maternity systems that, rhetorically, claim to promote ‘women-centred care’
but that routinely expect midwives to ‘talk women into’ going along with what-
ever the local guidelines stipulate. While being rigorous and comprehensive, the
text also conveys the everyday soul-damaging grind of trying to uphold values
of personalisation and choice, while being regularly gainsaid or even ostracised
by colleagues. Some of the accounts of moral distress and even of moral injury
are heart-breaking. They deserve to be heard alongside the accounts of women
and families whose lives are devastated by loss and harm, as equal casualties of a
system that seems to be unable to acknowledge that it does not always enable its
sta to enact its own rhetoric of woman-centred care.
However, alongside this clear-eyed critique of the harm caused by systems
that act in bad faith, Claire also provides a joyous picture of how it is for those
who are supported in the ‘everyday enactment’ of out of guidelines care. The sto-
ries of mutual collegiate support, care, true woman-centred care and autonomy,
trust and positive relationships are polar opposites of the harrowing accounts in
Foreword xxi
previous chapters. There is a sense of lightness and joy in the writing, and of an
emotional burden lifted – indeed of it never having been there in the rst place.
As Claire notes, this is the context in which midwives stay, women, birthing
people and partners have safe and positive birth experiences (no matter how their
baby is born) and there is a constant reservoir of hope and delight that underpins
positive resilience. The critical question is – how do we move from blame, grief,
fear and broken relationships in the everyday work of midwives towards joy,
delight and physical, emotional and psychological safety for all involved? This
book is an important and highly readable account of how this can and should
happen – and urgently, if the safety and wellbeing of ALL women and babies is
to be safeguarded into the future. As Claire says:
Unburdened by conict, a lessened mental and emotional load allowed the
midwives to not only get on with the job, but to ourish; experiencing
joy through relational care oered reciprocal gains, meaning-making and
personal aect. These experiences of joy, awe and wonder are a source of
resilience and likely contributing factors to why midwives stay.
Professor Soo Downe, University of Central Lancashire
PREFACE
A ‘normal’ physiological birth is one that starts spontaneously, progresses with-
out incident nor requires medical intervention and ends in a spontaneous birth
where the mother and baby are both well. Qualifying as a midwife in 2011, the
term ‘normal’ birth was typical vernacular to describe these types of births and
did not face the level of scrutiny or contention as the term does today – in the UK
at least. While the rate of ‘normal’ physiological births had been steadily declin-
ing and inter/intra-professional and public opinions were divided as to what
mode of birth was ‘best’ (as they continue to be), the terminology and concept of
physiological birth were not particularly contentious. Today, the landscape has
radically changed with ‘normal’ birth (spontaneous labour and birth) a site for
signicant tension and conict with sharp polarisation and deepening divides.
For birthing women and people who were failed by maternity services and did
not get the medical care they wanted, such as access to pharmacological pain
relief or caesarean sections, those situations have caused signicant distress and
trauma. Equally, there are birthing women and people denied access to the care
of their choosing, such as homebirths, birth centres, birthing pools, etc., or who
have felt coerced into accepting medical interventions they did not want. These
situations also cause signicant distress and trauma. For birth choices at either
end of the continuum, the common sense and humanised approach would be to
support and facilitate all births aligned with individual women’s needs. Yet, this
seems to be an enormous challenge in the UK maternity system.
This book is about physiological birth, specically the choices women have
actively made which sit ‘outside’ of maternity guidelines or recommendations
(I call alternative physiological birth choices). These choices include a vast array
of decisions from those with pre-existing medical disorders seeking midwifery-
led care (home/birth centre) or perhaps those preferring hospital but do not want
xxiv Preface
specic routine medical care or interventions, to those with healthy ‘low risk’
pregnancies declining aspects of care (and everything in between). Given the
immense scrutiny physiological birth faces, decisions outside of the guidelines
especially challenge the current rhetoric around maternal bodily autonomy, thus
warranted further investigation. The topic was borne out of a combination of my
own birth experience, clinical experience and previous research with women
preferring to opt outside of maternity care altogether, to freebirth, as maternity
services could not or would not meet their needs. Conducting those interviews
was heart-wrenching and awe-inspiring inuencing my research journey. I was
frustrated and angry on their behalf, the maternity services did not support their
decisions. The women’s initial decisions, wants and needs were not radical or
particularly taxing for a competent maternity professional, yet these women
faced obstacles and barriers and most experienced some level of trauma.
It was knowing that midwives (and obstetricians) elsewhere did have the skills,
competency and condence to facilitate a wide range of physiological births
(complex or otherwise) that informed my research direction. Birth (or mater-
nity care) trauma is hugely important, but going upstream and minimising its
occurrence in the rst place was compelling. Evidence now points us to caregiv-
ing as a key modiable risk factor for birth (maternity care) trauma where acts
of compassionate, respectful and dignied care safeguard and mitigate against
such trauma – this includes the proactive support and facilitation of birthing
choices. Therefore, I wanted to learn from those midwives who were managing
to provide physiological birth care deemed ‘outside of the guidelines’ and while
in NHS practice. Focusing on the midwives’ caregiving was an opportunity
to learn from the primary/lead carer for childbearing people in the UK whose
skillset should be optimising physiological processes. Moreover, midwives are
typically positioned as the mediators, arbitrators or gatekeepers for birth choices
so researching their practice would illuminate what could be achieved and a way
to explore the tensions existing around physiological birth. This book reects my
PhD work that recruited 45 NHS midwives self-dened as willingly support-
ive of these birth choices. Using three dierent analyses three dierent research
questions were asked and answered, how the midwives provided clinical care,
their experiences of doing so and the sociocultural-political workplace inuence
on their practice. Broadly, the ndings demonstrated the midwives’ workplace
context – the culture, politics and ethical values played a signicant role in their
ability to support women’s alternative physiological birthing choices. Resonating
with my freebirthing study, this book includes heart-breaking and awe-inspiring
accounts as the midwives navigated the maternity system to meet the needs of
those in their care.
This work has not been without its challenges or diculties, for life does not
stop for research (or clinical work for that matter), but it has been a joy and priv-
ilege to research with the 45 midwives in this study. They gave up their precious
time to contribute to the study and the wider evidence base, some in the most
perilous of circumstances. It is a known feature of midwifery practice that the
Preface xxv
art is passed down orally through storytelling, and these midwives did not disap-
point. I personally and professionally learnt so much from listening to their vast
array of experiences. I was moved by their steadfast commitment to the women
in their care and the degree of vulnerability they shared. Sharing these stories
with the wider maternity community has also been a privilege; connecting to
numerous audiences nationally and internationally a strong resonance with the
ndings has been evident. With thanks to the study participants who articulated
the hidden, unseen, ineable qualities of meaningful midwifery care, which has
connected with these audiences.
Conducting this research was not a solo eort, and I have heartfelt gratitude
for my patient supervisors, Prof Gill Thomson and Prof Soo Downe. Dr Carol
Kingdon, Dr Stephanie Heys, Dr Louise Hunt and Dr Naoimh McMahon
all provided valuable support during the PhD itself and of course, since then.
A big thank you to those who have supported this work in dierent ways,
too many to mention but a shout out to Anna and Sheena Byrom and The
Practising Midwife for the opportunities you have given me along the way.
Also, I am so grateful to the RCM, ARM and Birthrights who supported this
work by advertising the study; with their wide reach, I was able to recruit a
fantastic range of midwives from across the UK. I also owe Dr Jane Carpen-
ter a huge thank you as it was Jane’s introduction which led to this work in a
monograph format. Thanks are also due to the team at Routledge who have
been so helpful and supportive throughout this process. And of course, my
friends and family who have had to put up with yet another writing marathon
– thank you!
Fi nally, a huge thank you to ‘my’ midwives, Sandy Sinclair and Gemma Jones.
Whether they realised it or not, their ‘practising outside of the box’ facilitated
a much wanted joyful and empowering birth which was life-changing in every
which way. I owe you so much.
Claire Feeley, UK.
Sections of this book were originally published in journal articles, listed below.
However, changes have been made for the purposes of this book.
Chapter 3
Feeley, C., Thomson, G., Downe, S. (2020) Understanding how NHS midwives facili-
tate women’s alternative birthing choices: Findings from a feminist pragmatist study.
PLOS ONE 15(11), e0242508. https://doi.org/10.1371/journal.pone.0242508
Chapters 4 and 5
Feeley, C., Thomson, G., Downe. S. (2021) ‘Stories of distress versus fullment’: A narra-
tive inquiry of midwives’ experiences supporting alternative birth choices in the UK
National Health Service. Women and Birth, 35(5), e446–e55. https://doi.org/10.1016/j.
wombi.2021.11.003
xxvi Preface
Other publications associated with the study
Feeley, C., Thomson, G., & Downe S (2019). Caring for women making unconventional
birth choices: A meta-synthesis exploring the views, attitudes, and experiences of
midwives. Midwifery, 72, 50–59.
Feeley, C. (2022) The ASSET model: What midwives need to support alternative physi-
ological births (outwith guidelines). The Practising Midwife, 25(2), 26–30.
GLOSSARY
Alternative institutionalised birth settings either type of midwifery-led
birth centres; AMU: adjoined birth centred (within hospital grounds) or
FMU: free standing birth centre (independent of hospital).
Augmentation of labour articial methods to speed up labour.
Band the pay scale that operates within the NHS for nurses and midwives,
normally ranges from Band 5 (newly qualied midwife) to Band 8 a-c
(Consultant Midwife or Head of Midwifery or Director of Midwifery)
Breech baby is bottom rst in the womb.
Caesarean section surgical birth via the abdomen.
Caseloading women who are looked after by one midwife throughout the
childbearing continuum (with minor exceptions such as sick or holiday leave).
Continuity of carer where women are looked after by the same midwife
within small team of midwives throughout the childbirth continuum.
Continuous electronic fetal monitoring a machine that is used to monitor
the baby’s heartrate throughout labour using a doppler positioned on the
mother’s abdomen which is attached to the machine (also see telemetry).
Coordinator/shift lead a senior midwife on labour ward/delivery suite who
is in charge of the whole ward.
Core midwife a midwife that has a permanent job in one particular area i.e.
labour ward/delivery suite or postnatal ward or antenatal clinic.
Episiotomy a surgical cut to the perineum to aid delivery of the baby, com-
monly used in instrumental births, historically overused and can cause
increased levels of perineal damage.
Fragmented care model where women are seen by dierent (usually
unknown) caregivers (midwives or doctors) throughout the childbearing
continuum.
Grand-multipara a woman who has had over 5 births (also see multiparous).
xxviii Glossary
Group B Streptococcus a transient bacterial infection that can occur in
approximately 20% of women.
Hypothyroidism underactive thyroid.
Induction of labour articial method to initiate labour.
Instrumental births the use of forceps or ventouse to deliver the baby.
Integrated models where midwives oer continuity of care but work across
homebirth and birth centre settings.
Intermittent monitoring/auscultation listening to the baby’s heart rate at
recurrent times throughout the rst and second stage of labour; however,
this is not continuous. It is carried out using either a pinard or a handheld
doppler.
Intrapartum care caring for women during the labour and birthing period.
Meconium the faeces of an in-utero infant (whether presence of meconium is
deemed signicant depends upon gestation, stage of labour, presentation of
baby and fetal heart sounds).
Multiparous a woman who has given birth more than once (also see
grand-multipara).
Multi-professional team wider team that the midwife works with, could
include obstetricians, paediatricians, specialist doctors, management and GPs.
Pre-eclampsia toxaemia a potentially life-threatening disorder of preg-
nancy, only resolved by birth.
Polyhydramnios excessive amniotic uid in the amniotic sac.
Post-dates/post-term pregnancy beyond 40 weeks
Post-partum haemorrhage excessive bleeding after birth.
Prolonged slower than expected progress of particular stage of labour (also
see stalled).
Rotational midwife midwife who works on a rotational basis to dierent
departments i.e. labour ward/delivery suite, postnatal ward, antenatal clinic,
communit y.
Shoulder dystocia during birth, the baby’s shoulders get stuck and require
active intervention to free them - is life threatening if not resolved.
Stalled labour slower than expected progress of particular stage of labour
(also see prolonged).
Third degree tear laceration is a tear in the vaginal tissue, perineal skin and
perineal muscles that extend into the anal sphincter.
Traditional community settings relates to midwives working in the com-
munity, often with their own caseload of antenatal women and work on calls
for homebirths. However, they do not oer continuity of carer so are likely
to provide intrapartum care for women they have not met.
Transfer moving from homebirth or birth centre to hospital, normally associated
with complications of labour or during the immediate post-partum period.
Uterine rupture An obstetric emergency where both maternal and fetal lives
are at signicant risk as the uterus has ruptured.
Vaginal examination an internal examination to assess cervical changes.
Telemetry a wireless CEFM.
1
INTRODUCTION
This chapter sets the scene and introduces the research that focused on NHS mid-
wives facilitating ‘out of guidelines’ physiological birth choices (or as I refer to,
alternative physiological birth choices). Such decisions should, in theory, be upheld
within UK policy, guidelines and legislation; however, evidence suggests birthing
women and people can face moralistic opposition and restricted access to care of their
choosing. Therefore, bodily autonomy for some women is largely rhetorical. Echo-
ing wider, international literature, these issues are not unique to the UK. However,
within the context of a strong midwifery-led workforce, integrated maternity and
neonatal service infrastructure that supports birth in all settings and collaborative
working with medical professionals, it is a curious situation in which physiological
births outside of guidelines are a site for tension. Furthermore, midwives supporting
these birth choices too can experience conict when delivering their care. How-
ever, less was known regarding the experiences of midwives employed by the NHS,
who willingly facilitated alternative physiological birth care. As a signicant gap in
the evidence base, this study sought to ll it to provide practice-based research that
could be used to improve women’s access to and experiences of alternative phys-
iological birth care. Accordingly, this chapter rst provides a discussion regarding
the contemporary international evidence and debates surrounding childbirth and
midwifery-led care. Second, ‘alternative physiological births’ are explained and the
justication for exploring these issues from the midwives’ perspectives is provided.
Finally, an overview of the research is presented, providing insights into the partic-
ipants, data collection and analysis to contextualise the rest of the book.
Childbirth and midwifery: Setting the scene
Birth is a biopsychosocial-cultural event with dierent layers of meaning depend-
ing on whose perspective. How birth is viewed, experienced and facilitated are
DOI: 10.4324/9781003265443-1
2 Introduction
inuenced by sociocultural-political contexts. Midwives, as the lead professionals
of childbearing women (in many countries, though not all), are at the forefront
and in the middle of these complex sociocultural and political discourses that
inuence childbirth practices. Childbirth practices – the overall delivery of ser-
vice provision and individual acts of care, procedures or interventions carried out
by obstetricians and midwives – have signicant ramications on the experiences
and life courses of those receiving care (Renfrew et al., 2014). Concurrently,
how people experience and interpret receiving care and their birth experiences is
also shaped by biopsychosocial-cultural expectations (Davis-Floyd & Cheyney,
2009; Downe et al., 2018). These are continually shaped and co-constructed
within societies as tides turn, favour shifts, wants or expectations change. Birth
can be a highly contested and politically charged space, with vehement views
often in opposition1. For some, physiological birth and midwifery care is the
anathema to quality maternity care. For others, me included, both physiological
birth (where this is safe and possible2) and midwifery care are viewed as having
intrinsic value. Although, these are not mutually exclusive, as some women will
birth uneventfully without a midwife (McKenzie & Montgomery, 2021). More-
over, quality, skilled, relational midwifery care supersedes the eventual mode of
birth (Tunçalp et al., 2015; White Ribbon Alliance, 2013; WHO, 2021). Where
midwifery care is grounded in respectful and dignied care, the overall biopsy-
chosocial experience and outcomes are enhanced regardless of whether a birth
was physiological or required medical support or intervention (Morton & Sim-
kin, 2019; Shakibazadeh et al., 2018).3 Therefore, midwifery care is vital for all
women during birth. These views are supported by robust international evidence
explored in this chapter and the next.
Midwifery as a profession, midwives as individuals, face ongoing power bat-
tles within the professional space of caregiving – often positioned as subservient
to obstetric practices and institutional demands (McFarland et al., 2019).4 More-
over, internationally, midwifery and midwives are undervalued with marked
underinvestment – demonstrated by the growing global crisis of workforce
shortages (UNFPA et al., 2021). Lack of investment in a neoliberal capitalist
society indicates where power holders (those with political and nancial power)
perceive value (Dahlen, H. et al., 2022; Fine & Saad-Filho, 2017). Low invest-
ment in midwifery and midwives indicates low status and value, mirroring the
broader undervaluing of women, childbearing and mothering (Filby et al., 2016;
Renfrew & Malata, 2021). With quality midwifery demonstrating positive bene-
ts for over 56 maternal and neonatal outcomes including reductions in maternal
mortality and infant stillbirths (Renfrew et al., 2014), lack of investment and
valuing of midwifery has serious consequences (Kennedy et al., 2018; Renfrew &
Malata, 2021). The burden of underinvestment and poor outcomes are mostly
felt by low-income countries (Filby et al., 2016), where ‘too little medicine’ such
as resources, facilities, life-saving medications or interventions and skilled care
is patchy, entirely lacking or inaccessible to women (Miller et al., 2016). How-
ever, issues within high-income countries are typically felt to be around ‘too
Introduction 3
much medicine’ (Miller et al., 2016) where the overuse of medical interventions
tips over from benecial to becoming harmful (WHO, 2018b). While this is a
crude simplication, the issues are more complex; essentially, there is a global
midwifery and birthing crisis (White Ribbon Alliance, 2022). While unevenly
distributed, even in places with midwives as lead professionals for childbearing
women, struggles with underinvestment, inadequate pay and working condi-
tions have created dangerous shortages (UNFPA et al., 2021);5 and power strug-
gles continue (White Ribbon Alliance, 2022). Crucially, these issues (and many
more) detrimentally impact childbearing outcomes: physically, mentally and
emotionally with far-reaching consequences across the mother-baby dyad’s life
courses.
‘Normal’ physiological birth is also a contested site with associated power
struggles (Lyerly, 2012; Lynch, 2020; Royal College of Midwives, 2022c). The
use of the word ‘normal’ and its direct implications in comparison to what is
deemed ‘abnormal’, over time, has been critiqued around implicit or explicit
moralising or stigmatising judgements (Bartlett, 2011; Rost, 2021; Winance,
2007). However, in terms of ‘normal birth’, this term has typically been used
as an abridged colloquialism referring to ‘normal physiological labour and
birth’ – the biological processes of labour and birth which have been studied
through the basic sciences, anatomy, physiology, epidemiology, observational
and interventional studies. This body of evidence is not a moral judgment of
‘normal vs abnormal’ to which critics claim (Lyerly, 2012); rather, through
these studies, the parameters of a physiological birth have been broadly deter-
mined, international denitions generated and complications of birth studied to
help identify key markers for births that require lifesaving assistance (Renfrew
et al., 2014; WHO, 2018a). Broadly, physiological birth is one where labour
starts spontaneously, proceeds without incident (problem or emergency), nor
requires intervention, and results in a spontaneous birth, with mother and baby
well.6 The conation of normal physiological birth with ‘any’ vaginal birth that
may involve induction, augmentation and instrumental birth has added heat to a
polarised debate (Beech, 2017; Feeley, 2021). Moreover, there are concerns that
proponents of (exclusively) medicalised births are against the concept of normal
physiological labour and birth rather than the language of ‘normal’ (Beech, 2017;
Gutteridge, 2022), to which compelling arguments exist (outlined above). Those
against the concept of physiological labour and birth contradict the compelling
international qualitative insights nding that most women (not all) anticipate and
want a normal physiological birth, crucially, expecting their maternity caregiver
to be skilled to facilitate that safely (Downe et al., 2018).7
A ‘normal’ physiological birth has important psychosocial and biological
benets for mothers and babies (Renfrew & Malata, 2021; The Lancet, 2018).
Physiological births are associated with enhanced experiences of a positive birth
(Hildingsoon et al., 2013; Olza et al., 2018), greater levels of maternal-infant
attachment (Romano & Lothian, 2008), less infant complications such as res-
piratory or other chronic metabolic illnesses (Dahlen, H. et al., 2013), (including
4 Introduction
less respiratory disorders in children up to 16 years old) (Dahlen, H. et al., 2021),
higher breastfeeding initiation and continuation rates which have signicant
maternal-infant health benets (Rollins et al., 2016), and reduced complications
in subsequent pregnancies (WHO, 2018c). The benets of physiological births
are also related to reducing the potential harms of routine8 interventions includ-
ing induction of labour, augmentation of labour, continuous electronic monitor-
ing, episiotomies, instrumental births, or caesarean sections (ten Hoope-Bender
et al., 2014; The Lancet, 2018). These routine procedures are often associated
with hospital institutionalised birth practices (Johanson et al., 2002). Although
many procedures can be lifesaving (The Lancet, 2018), the exponential rise
in birth interventions over the past 20–30 years have raised concerns that too
much medicine outweighs the benets of their use, thus causing iatrogenic harm
(Renfrew et al., 2014; WHO, 2018c). Recent international eorts have focused
attention on reducing unnecessary and harmful interventions signalling a shift
away from unwarranted medical technocratic birth practices.9
Getting the balance of ‘enough medicine’ (and/or care), not too much, not too
little, is an essential component of quality maternity care (Miller et al., 2016). To
which, midwifery is vital both to ensure the protection of physiological processes
and to provide timely appropriate referrals or lifesaving interventions (Renfrew
et al., 2014). The Lancet Midwifery Series (Renfrew et al., 2014), the largest
review carried out, examined 13 meta-syntheses and 173 systematic reviews that
determined that midwifery ‘is a vital solution to the challenges of providing
high-quality maternal and newborn care for all women and newborn infants,
in all countries’ (p. 8). Moreover, central to quality midwifery/maternity10 care
is the relational aspects between the mother-caregiver (Walsh & Devane, 2012).
When meaningful relationships are cultivated, trust and mutual respect occur,
women’s experiences are enhanced, and safety within a holistic perspective is
ensured (Downe et al., 2018; Walsh & Devane, 2012).11 The bedrock of rela-
tional care is centring on the needs of birthing women and people, working
in partnership and collaboration, and arming their human rights and dignity
throughout (Shakibazadeh et al., 2018). This includes supporting autonomous
decision-making, irrespective of the beliefs held by the midwife or obstetrician.
Facilitating or ensuring women’s agency is a core component of midwifery prac-
tice, underpinned by respectful care, an enabling relationship ensures power
and control remain held by the woman with positive benets beyond the birth
experience (Thomson & Feeley, 2019). Where women feel disempowered, dis-
respected, or experience a lack of control, evidence demonstrates a long-lasting
negative impact, including birth trauma (Reed et al., 2017).
’Alternative’ physiological birth: Autonomy, choice and tensions
Having dened and explained physiological birth, in this research, I dened
‘alternative’ physiological birth choices as ‘birth choices that go outside of local/
national maternity guidelines or when women decline recommended treatment
Introduction 5
of care, in the pursuit of a physiological birth’ (Feeley, 2019). Such characterisa-
tion excludes birth choices that go outside of maternity guidelines where women
are seeking increased medical surveillance and/or medical interventions such as
elective induction of labour or caesarean. The distinction between both types
of birth choices is important. The premise for this research relates to dominant
sociocultural-political discourses of medicalisation, technocratic, risk-averse and
institutionalisation that has shaped childbirth practices in the UK (and beyond).12
These discourses have been attributed to creating hegemonic birth practices
(Clesse et al., 2018) to the detriment of physiological birth rates (WHO, 2018c),
women’s choices when seeking a physiological birth (Holten & de Miranda,
2016) and midwives’ ability to provide evidence-based and woman-centred care
within their skillset of facilitating physiological birth (Cooper, 2011; Davis &
Homer, 2016; Newnham & Kirkham, 2019). This focus does not negate the
importance of supporting all birth choices and women’s autonomy – which is
central to ethical care. However, physiological birth and ‘alternative physiolog-
ical birth’ fall under the direct remit of midwifery practice, as mentioned, a site
for tensions and conict that this research sought to explore. Moreover, within
the context of declining physiological birth rates, exploring ‘alternative’ physi-
ological births provides a window to examine the sociocultural-political com-
plexities around birth practices, autonomy, choice, and their tensions.
The ability/opportunity for women to make ‘choices’ during pregnancy and
childbirth is embedded within governmental policies, cultural norms and wom-
en’s expectations. Such rhetoric is also associated with the global movement
for improved human rights during childbirth that includes respect for women’s
decision-making and autonomy, including the right to decline recommended
care or treatment (ICI, 2021; White Ribbon Alliance, 2011). However, evidence
suggests that women can face opposition, conict, reprisals and restrictive care
provision when they attempt to challenge technocratic, medicalised, risk-averse
and institutionalised hegemonic birth practices (Feeley & Thomson, 2016a;
Roberts & Walsh, 2018).13 Alternative physiological birth choices, as previously
dened, may include healthy women declining routine maternity care practices
such as labour induction after 41 weeks of gestation, or vaginal examinations
to assess the progress of labour or fetal monitoring during labour. Other situ-
ations include women who have had medical or obstetric risk factors seeking
midwifery-led care and/or non-obstetric settings (home or birth centres). Deci-
sions that resist these discourses can be perceived as controversial despite legisla-
tion that assures women’s bodily autonomy and rights to choose their care.
Although studies have explored women’s decision-making and experiences of
alternative physiological birthing choices14, few at the time of this research had
examined the views and experiences of midwives caring for them.15 This was
an important gap as ‘full-scope’ midwifery as dened by the Lancet (Renfrew
et al., 2014), includes the optimisation of normal biological, psychological, social
and cultural processes whilst respecting women’s individual circumstances and
views. Therefore, the facilitation of alternative physiological births directly falls
6 Introduction
within this remit and concurs with the international denition of midwifery
(International Confederation of Midwives, 2014, 2017) and the midwifery phi-
losophy of woman-centred individualised care (Bradeld et al., 2018). This lack
of attention was and still is signicant because women’s ability to assert their
agency can be inuenced positively or negatively by their midwife caregivers
(Coxon et al., 2017). Such inuence may be related to the midwives’ personal
philosophy of childbirth (Cooper, 2011), personal experiences of birth (Church,
2014), professional experiences of birth (Daemers et al., 2017), skill sets (Walker
et al., 2018), perceptions of risk (Coxon et al., 2017) or how they value women’s
autonomy (Kruske et al., 2013).
In addition, midwives’ ability to practice can be inuenced positively or
negatively by their sociocultural and political working contexts (Newnham &
Kirkham, 2019; Nilsson et al., 2019), with of course additional challenges now
related to the COVID-19 pandemic (Berg et al., 2022). In the UK, and other
similar high-income contexts most women receive care commissioned by
institutions (e.g., the UK NHS). Although institutions such as the NHS have
excellent outcomes at the population level (DH, 2021),16 its scale lends itself
to routine, procedural, bureaucratic-driven care at the expense of individual-
ised, relational care, women’s ability to assert agency and their experiences of
care (further discussed in Chapter 2). Moreover, organisational issues such as
medicalised, risk-averse, technocratic cultures, poor stang and busy workloads
can limit midwives’ ability to practice autonomously (Davis & Homer, 2016;
Vermeulen et al., 2019). As such, institutional limitations to midwifery practice
can adversely aect women’s access to individualised woman-centred care and
skilled physiological birth care. For example, evidence shows for similar cohorts
of women (health status/risk prole), where they give birth strongly inuences
their outcomes i.e., signicantly less likelihood of a physiological birth in hospi-
tal settings (Brocklehurst, 2011; Reitsma et al., 2020).17 It is within ndings such
as these that we can explore the institutional and sociocultural-political impact
and inuence upon birth practices and outcomes.
A core issue within institutional maternity care can be captured as ‘guideline-
centred’ care (Kotaska, 2011). Guidelines are used throughout health and social
care in the UK (also common elsewhere) and are embedded into governance
processes, procedures and insurance statuses of hospitals (Weisz et al., 2007).
Used well, guidelines are structured documents with focused information about
a given topic including care practice information on what to consider doing,
when and why. Used poorly, guidelines distil and perpetuate routine, proce-
dural and bureaucratic-driven care at the expense of individual patient auton-
omy and professional expertise (Greenhalgh, 2018; Wieringa & Greenhalgh,
2015). Issues arise when they are used as ‘rule books’ – a prescriptive approach to
healthcare whereby punitive action may occur should a professional or a person
receiving care does not follow the prescribed guideline (Alexander & Bogos-
sian, 2018; Symon, 2000). As an unintended consequence of the proliferation of
guidelines across healthcare, alongside astounding maternity litigation claims,
Introduction 7
guideline adherence has become synonymous with ‘safe’ care or rather, care that
can be defended in the event of a claim (Alexander & Bogossian, 2018; Grith &
Tengnah, 2010). Therefore, opting ‘outside of guidelines’, the basis of this study,
can be viewed as deviant or problematic, despite the centrality of individualised
care within policy, legislation, international and national guidance and profes-
sional obligations18 to ensure care wraps around the needs of those receiving
care. The chasm between policy rhetoric, legislation, best practice and the reality
for both professionals and birthing women is central to this research whereby sig-
nicant tensions between large-scale institutional delivery of maternity services,
individualised care and physiological birth exist.
Independent and employed midwives
It is important to dierentiate between independent/private and employed mid-
wives. Central to this book are the experiences of employed midwives deliv-
ering alternative physiological birth care within the constraints of institutional
working. While the place of midwifery practice may be dierent (community,
birth centre or hospital), employed midwives are subjected to employee obliga-
tions, expectations and terms of their contract. Some employee requirements are
explicit and failing to adhere would mean termination of the contract (Royal
College of Midwives, 2022a). Other requirements are implicit, cultural artefacts
such as strict guideline adherence are subject to interpretation depending on
the organisational, social and political culture (Feeley et al., 2021). While there
are enormous challenges for midwives working independently (self-employed)
across the globe, they do have relative autonomy and freedom to practice with-
out rigid structures associated with large-scale organisational working. Broadly,
independent midwives are known for providing a ‘gold standard of care’ – a case-
loading model in which they are the sole care provider for a particular woman
and family throughout the childbearing journey (Frohlich, 2007). This way of
working allows the time and space to build intimate trusting relationships with-
out the bureaucratic and time pressures employed midwives face (Wickham,
2010). By virtue of this way of working, individualised care irrespective of health
status can be actualised. Therefore, independent midwives are well known for
their skills and desire to support alternative physiological births. This was cap-
tured in a systematic review (Feeley et al., 2019) of the literature that explored
midwives’ views of these birthing decisions and found independent midwives
‘willingly facilitative’ of these birth choices – based on strongly held beliefs of
women’s autonomy coupled with appropriate skills to deliver this care.
However, independent midwifery practice is also subjected to ongoing polit-
ical battles. For example, in the UK, independent midwives had been denied
insurance products since June 2020 (IMUK, 2020), which has only recently
been resolved (Zest, 2022).19 In the US, midwives in some states are not recog-
nised legally and professionally; thus, integration into the wider health system
is inconsistent (Vedam et al., 2018). New Zealand has had an established model
8 Introduction
of independent midwives (Lead Maternity Care Providers) reimbursed by the
government to deliver care (Grigg & Tracy, 2013). However, low pay and poor
working conditions have stimulated several court proceedings to address pay
inequity and discrimination (New Zealand College of Midwives, 2017). Echo-
ing New Zealand, Canadian midwives working within a similar model of inde-
pendence renumerated by the government, have won three court proceedings
regarding poor inequitable pay, yet the government is yet to provide the pay
lift they have been awarded (Association of Ontario Midwives, 2022). Draw-
ing attention to the challenges independent midwives face further highlights
the impact of broader sociocultural-political issues already discussed. Given the
world is short of 900,000 midwives (UNFPA et al., 2021), the issues independent
midwives face reiterate the overall undervaluing of the profession and the bene-
ts to a childbearing population. While the rest of this book focuses on employed
midwives, it is important to recognise independent midwifery is also a site for
political struggle and tension, albeit with dierent challenges to those employed.
The research
This book centres on research that captured narrative accounts and interviews
from NHS-employed midwives, who were self-dened as facilitative of alterna-
tive physiological birth choices. The research was underpinned by a feminist prag-
matist theoretical framework that ontologically focuses on ‘real world’ problems
whereby knowledge generation is utilised to aect positive social change (Fischer,
2014; Seigfried, 1996). Feminist pragmatists are aligned with pragmatist perspec-
tives in conjunction with broad feminist theories that perceive that knowledge is
constructed, contingent and intrinsically political (McHugh, 2015). Therefore,
feminist pragmatism inherently adopts a critical perspective to account for issues
of gender, power and structural inuences in people’s experiences, the meaning-
making attributed to experiences as well as the production of knowledge
(Fischer, 2014; Seigfried, 1996). Feminist pragmatism was justied for this study
as the research questions pose a feminist inquiry - it centers on midwives’ (a
female-dominated profession) and women’s birth choices. Women’s bodies as a
site for power, control and regulation have long been discussed (Davis-Floyd &
Cheyney, 2009; Kitzinger, 2005; Newnham, 2014), with feminists arguing that
structural paternalism marginalises women’s ways of knowing, access to equita-
ble services and autonomous decision making. Additionally, the midwifery pro-
fession is also a site for power, control and regulation as outlined in this chapter.
In this study, midwives were viewed as ‘situated knowers’ (McHugh, 2015) with
the capacity to generate bottom-up, practice-based knowledge. By using a nar-
rative research methodology, where stories/narratives are viewed as knowledge
devices (Bamberg, 2010), the midwives’ situated knowledge was captured and
analysed via stories of professional practice.
45 midwives generously gave up their time to participate, to share their prac-
tice-based stories and experiences of delivering this type of maternity care. My
Introduction 9
core focus was to collect practice-based stories that related to any physiological
birth choice deemed outside of the guidelines. Taking such a broad approach was
to move beyond specic decisions or clinical scenarios such as focusing only on
home vaginal birth after caesarean or water breech births etc. Instead, the aim was
to develop practice-based knowledge and insights that could be applied to any
birth choice, to elucidate the principles of midwifery practice in this context as well
as examine the experiences and sociocultural-political inuences on delivering
‘out of guidelines’ care. Accordingly, I had three key research questions to answer,
to nd out how midwives delivered this care so that practice-based evidence could
be used for other midwives and maternity professionals within their practice.
I also wanted to understand their experiences of doing so, what was it like for the
midwives? Then taking a broader view, I wanted to examine the intersection,
inuence and impact of social, cultural and political discourses on their practice
and experiences in delivering care. To answer these three research questions, three
dierent narrative analyses were carried out, one building on the other.20
The midwives recruited for the study were mostly employed by dierent
organisations (known as hospital Trusts)21 from across the UK. This provided
data and analyses to generate broader insights and perspectives, beyond that of a
localised culture, for the same reason as above. The midwife participants were
diverse in several ways (see Appendix 1): working in dierent settings (com-
munity, birth centres, hospital), working in dierent roles, in dierent models
(continuity or fragmented), with dierent levels of experience (<2 years qual-
ied to >30) and levels of seniority ( junior/senior/management). Such diver-
sity strengthened the ndings, moving the discussion beyond specic midwifery
settings, models and levels of experience, demonstrating this type of care is not
contingent on particular parameters which may be subject to polarisation i.e.
home vs hospital, continuity vs fragmented models of care, inexperienced vs
experienced midwives, junior/seniority, etc. This study demonstrates that facili-
tating alternative physiological births is within the remit of any and all midwives
across all maternity settings.
I invited the midwives to either write a reective account (self-written narra-
tive) or have an interview, with many opting to do both. Starting with an open
question, the midwives either wrote or told me about a specic alternative phys-
iological birth they had facilitated. In interviews, this initial practice example
paved the way for a wide-ranging conversation that spanned numerous alterna-
tive physiological births, the midwives’ own experiences of birth, their attitudes
and beliefs etc. In all the interviews and some of the written accounts, the mid-
wives wove in stories about their workplace environments and how where they
worked aected them personally, through the caregiving approach they adopted.
Some were heart breaking accounts of isolation, ostracisation and bullying. Oth-
ers were uplifting accounts of workplace friendship, camaraderie and support.
All, of course, worked within the same broad societal landscape of opposing and
conicting sociocultural-political discourses, so for their experiences to be so
dierent was a surprising element of the study.
10 Introduction
It is also important to note the context at the time of recruitment. Data was
collected in 2017, during a time of great change, the Francis (2013) and Kirkup
(2015) reports exposed two failing hospitals with signicant implications for
maternity services. Among many changes, this resulted in supervision22 being
removed from legislative statute (DH, 2017; Parliamentary and Health Service
Ombudsman, 2013), Nursing and Midwifery Council23 changes (DH, 2017;
NMC, 2015), increased scrutiny and concerns around ‘normal’ birth including
a turn in media reporting condemning midwives, midwifery practice and ‘nor-
mal’ birth (Darling, 2021; Spain, 2022). More recently, the publication of the
Ockendon Report (2022) exposed maternity service failings within another
Trust, to which midwives and physiological birth have come under greater
pressure by the media.24 These challenges, further contextualised by 12 years
of austerity, Brexit and the COVID-19 pandemic have co-created signicant
workforce issues around recruitment, retention and appropriately skilled mater-
nity provision (Royal College of Midwives, 2022b). Thus, the UK landscape for
the midwife participants was rocky then and has been increasingly destabilised
since. Particularly around the value of midwifery care, women’s choices and
physiological birth practices – homebirth, birth centre and waterbirth services
are frequently closed, continuity teams are being disbanded (Birthrights, 2022),
and greater paternalistic narratives dominate the UK landscape. Therefore, the
study ndings maintain relevance and are perhaps needed more now than before.
As polarised debates deepen in the UK, we must learn from midwives who are
practising within the system to support birthing women and people’s physiolog-
ical birth choices.
Conclusion
This chapter has set the scene for this book and the research carried out. While
the ndings presented have been collected from a UK context, they resonate
across dierent high-income country contexts. For example, researchers in
the Netherlands, Australia, the US and Canada have been asking similar ques-
tions, exploring the nature of maternity service provision and whether it meets
women’s needs (or not) – see endnote 14. Moreover, having presented at many
international conferences and webinars, the feedback from many international
midwives is one of resonance with their working context. However, interna-
tional dierences exist in terms of what may be deemed ‘alternative’ or out of
guidelines. For example, Newnham et al. (2018) situate homebirth itself as an
alternative birth choice and water birth in Hong Kong may be deemed alterna-
tive.25 Notwithstanding these specic dierences, again highlighting the inu-
ence of sociocultural-political contexts, the core message remains – women’s
choices for physiological birth and midwives’ ability to deliver the care women
want and expect are frequently constrained. ‘Not being allowed’ to do the job
they are educated to do is a recurring message of why midwives leave the profes-
sion (RCM, 2016; UNFPA et al., 2021; White Ribbon Alliance, 2022). While
Introduction 11
what midwives (and women) are not allowed to do may look dierent in dier-
ent countries, and some of the examples presented in this book may feel extraor-
dinarily radical to some midwives, the broad issues are persistently consistent.
In the next chapter, we will explore the intersecting discourses that give rise to
hegemonic birth practices to create tensions between the rhetoric and reality of
supporting and facilitating physiological birth.
Notes
1 For example, homebirth is a contested space internationally. A meta-analysis car-
ried out by Wax et al. (2010) cited an alarming tripling of neonatal mortality. This
generated a signicant number of refutations, example here (Sandall et al., 2011)
and the Editor’s of AJOG responding to the number of letters they received (AJOG
Editorial Team, 2011). This is one example of many areas of contention across the
physiological birth with longstanding discussion and disagreements generally framed
as a dichotomy as either ‘birth as a risky event’, only safe in retrospect or ‘birth as a
normal life event’ sometimes requiring help/interventions (Johanson et al., 2002).
While the conversation is moving on to consider humanised birth approaches, appro-
priate and judicious interventions for the right person at the right time, see Miller
et al. (2016), dichotomous thinking is still evident in practice. As the birth binaries
has been the subject of many books and articles, I have refrained from too much detail
here, assuming you, the reader is aware of these issues.
2 Being physiologically informed does not negate the necessity for appropriate, judi-
cious medical interventions where that is needed and wanted by birthing women and
people (Feeley et al., 2020).
3 The converse is also true with growing evidence indicating that ‘birth trauma’ may
be reconceptualised as ‘maternity care trauma’ as studies nd negative, disrespectful,
undignied care and fractured relationships with maternity providers as a leading
cause of distress and traumatic experience see- (Bohren et al., 2015; Feeley & Thom-
son, 2016b; Reed et al., 2017; Thomson & Downe, 2008).
4 Longstanding power struggles have been analysed and critiqued by several feminist
academics. In brief, midwives have been demonised since the Middle Ages (Newn-
ham, 2014). Further vilication occurred during the 17th and 18th century, as cen-
turies of systematic exclusion of women from medicine, science and religion entered
the birthing sphere (Cahill, 2000). Stacey (1988) suggested that the small number of
men-midwives that began to successfully deliver (live) babies with forceps challenged
the tradition of birth within the female domestic arena. Capitalising upon the emer-
gence of ‘scientic knowledge’ as morally superior, a systematic devaluing of mid-
wifery ‘traditional’ knowledge occurred (Cahill, 2000; Stacey, 1988). The rise of the
medical market, medical ‘professionalisation’ and subsequent dominance of doctors
grew in all areas of health whereby to assert authority required a proactive strategy to
vilify and undermine midwives (amongst other competitors) (Stacey, 1988).
5 This report was published in 2021, since then, growing news coverage from a
range of countries report a ‘mass exodus’ of midwives and/or ongoing shortages.
For example, Canada https://globalnews.ca/news/8813886/midwife- shortage-
abbotsford-bc/; Australia https://www.theguardian.com/ australia-news/2022/
apr/13/babies- missing-out-on-health-checks-in-melbourne-due-to-covid-
related-workforce-shortages the UK https://inews.co.uk/news/health/top-midwife-
maternity-shortage- increasingly-more-difficult-safe-care-1550717; New Zea-
land https://www.nzherald.co.nz/bay-of-plenty-times/news/bay-of-plenty-
midwife-shortage-midwives-from- other-regions-called-to-help/2EBFSKFDH
ETQXASLHO4LDVZR4A/#:~:text = While %20 the %20 Bay %20 of %20
Plenty, throughout %20 New %20 Zealand %20 Maternity %20 Services.
12 Introduction
6 There are some variations across the globe regarding the denition of a physiological
birth, often the ‘risk’ status of the woman will be used to dene a normal physiologi-
cal birth i.e. low risk at the onset of labour (and remaining low risk) and/or where the
fetus is head down rather than breech presenting (International Confederation, 2014;
WHO, 1996), to which there is some disagreement. For example, those with obstet-
ric or medical complexities often will go into spontaneous labour, proceed without
complication or intervention and have a spontaneous physiological birth – such is the
subject of this study! Therefore, I’ve opted to use this broad denition to circumvent
these debatable variations.
7 The qualitative systematic review while nding that most women desired and
anticipated a normal birth, women were also prepared that labour and/or birth may
require assistance or intervention, recognising there was need to ‘go with the ow’
(Downe et al., 2018), therefore, women’s expectations around a normal birth are not
‘at any cost’.
8 These interventions can be lifesaving, however, the balance tips to harm when used
routinely, injudiciously.
9 See (Miller et al., 2016; Renfrew & Malata, 2021; Renfrew et al., 2014; ten Hoope-
Bender et al., 2014; The Lancet, 2018; WHO, 2018c).
10 Relational care characterised by meaningful connection and trust is essential for
all health and social care professionals. However, in maternity care, its presence or
absence has an exceptionally strong impact due to the emotional and life-long impact
of childbearing.
11 Concepts of safety in maternity care will be explored further in Chapter 2, however,
it is essential to view safety within a broader lens and must include psychological,
cultural and spiritual safety.
12 For an insightful and recent global perspective, see the special issue in Health, Risk &
Society. It includes sophisticated considerations of these issues, collating papers
from Brazil, Jordan, Switzerland, Turkey, China, Japan, Italy and Senegal (Topçu &
Brown, 2019).
13 Also see ( Jackson et al., 2012; Keedle et al., 2015; Plested & Kirkham, 2016; Scamell,
2014; Shallow, 2013; Viisainen, 2000) to name a few studies.
14 Studies have explored women’s experiences of alternative birth choices include:
freebirthing, which is an active decision to give birth with no professional’s present
(Dahlen, H. G. et al., 2011; Feeley & Thomson, 2016; Freeze & Tanner, 2020; Jack-
son et al., 2012; McKenzie & Montgomer y, 2021; Miller, A. C., 2009); ‘high-risk’
homebirths (Hollander, Holten, Leusink et al., 2018); vaginal birth after caesarean
(VBAC) at home or in a birth pool (Keedle et al., 2015; McKenna & Symon, 2014).
15 Exploring the experiences of maternity professionals in relation to alternative phys-
iological births is now a rapidly growing area of international scholarship e.g. The
Netherlands (Hollander et al., 2019), Canada (Wines, 2016), Australia (Jenkinson
et al., 2017). While the book Birthing outside the system: The canar y in the coalm-
ine largely focused on women’s motivations and experiences, several chapters share
insights from maternity professionals (Dahlen, H. et al., 2020). Additionally, with
personal contact with many researchers in this eld, new studies are in their early
stages of development.
16 Although, to caveat this point, signicant disparities exist in high-income countries –
Black, Asian and women from minority groups experience worse maternal/neonatal
outcomes, with Black women suering the most signicant impact (Adane et al.,
2020; Howell, 2018; Knight et al., 2022; Urquia et al., 2017).
17 The ndings from the UK Birthplace Study (Brocklehurst, 2011) demonstrated the
relationship between the intended place of birth with birth outcomes in 64,538 low
risk women. It found that women (of similar cohorts, health and risk status) were sig-
nicantly less likely to have a vaginal birth if they planned to birth in an OU i.e. 58%,
compared to; 76% for planned births at a birth centre attached to hospital, 83% for
Introduction 13
planned births at a free-standing birth centre, 88% for planned births at home. These
are collated gures of both rst and second (or more) time mothers. These gures
demonstrate that for the majority of (low risk) women choosing to birth in hospital
reduces their chance of a physiological birth and its associated benets.
18 In the UK, (similar to many countries) health professionals are regulated. Their reg-
ulators set down frameworks of expected practice health professionals are duty bound
to follow. Personalised, individualised care is a common professional obligation, yet,
is found lacking due to institutional constraints such as an over emphasis on comply-
ing with guidelines.
19 Lack of political will to address the UK Independent Midwives (IM) insurance is
ongoing – despite the profound impact that COVID-19 has had on NHS midwives
and women’s choices such as homebirth service suspensions, to which IM’s could have
been enabled to provide (IMUK, 2020). (This was true at the time of writing, how-
ever, now a product has been found (Zest, 2022), but only due to tenacious midwives
making it happen.)
20 I have purposefully avoided including dense methodological information, hoping to
ensure this book is accessible to all readers. For those interested in extensive method-
ological insights please see (Feeley, 2019).
21 In the UK, the NHS is divided into ‘hospital Trusts’ which are commissioned to
deliver services in specic geographical areas. A ‘Trust’ providing maternity ser vices
typically includes hospital settings (the dominant place), community midwifery ser-
vices for homebirth provision, antenatal/postnatal care (sometimes in conjunction
with GP surgeries) and may include birth centre provision (free standing or adjoined
within the hospital). Therefore, a ‘Trust’ is responsible for all maternity service pro-
vision, employment of the sta across the dierent areas, and operate under the same
employment contracts, policies, guidelines etc.
2 2 For midwifery, supervision was a statutory responsibility which provided a mech-
anism for support and guidance to every midwife practising in the UK. The stated
purpose of supervision of midwives was to protect women and babies by actively
promoting a safe standard of midwifery practice, however, failings of this mechanism
were found in the Francis Report which led to its statutor y removal (Francis, 2013;
Parliamentary and Health Service Ombudsman, 2013).
2 3 The NMC is the regulatory body for nurses and midwives in the UK and were impli-
cated in the failings at Morecombe Bay (Francis, 2013; Parliamentary and Health
Service Ombudsman, 2013).
24 Media reporting of the Ockendon report has focused onerously on midwifery care
and physiological birth, despite tragic outcomes being evidenced as ‘routine medical-
ised approaches to birth’ such as high levels of induction, syntocinon, poorly skilled
obstetric instrumental births which coupled along with poor stang and teamwork
arguably, co-created poor outcomes, rather than physiological labour and birth per se.
The conation between ‘any’ vaginal birth and physiological birth as dened here has
been a source of much tension and debate see my analysis (Feeley, 2021). Moreover,
the Ockendon Report highlighted managerial cover-ups, poor governance structures
and processes for investigations when adverse events occurred – these components are
beyond the remit of most midwives and obstetricians in everyday practice (Ocken-
don, 2022).
25 During my MSc I had the pleasure of learning with 20+ midwives from Hong Kong
who joined u s at the Univers ity of Centra l Lanca shire for a ‘norm al’ bir th module. Du r-
ing this intensive week they shared their clinical practice and working contexts which
included their limitations, such as water for labour/birth is not typically facilitated. I
was unable to nd academic references to this point, but have included reports to illus-
trate this example of what is deemed ‘alternative’ diers depending on the context,
see http://tyr.jour.hkbu.edu.hk/2013/03/20/water-birth-yet-to-gain-acceptance/
https://www.otandp.com/blog/water-birth-in-hong-kong
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