N is for Normal
Today we reached N in the #MatExp ABC and that brings me to "Normal" birth. Regular readers of this blog will have noted that I tend to put normal in " " and may also have guessed that that is because I'm not very keen on the the phrase.
One of the things often discussed using the #MatExp hashtag on twitter is the power of the language used when talking about birth. For example, I know that a lot of Mums and some medical professionals dislike the term "failure to progress". It's a technical term and intends no judgement on the mother's efforts, but the word failure is of course very emotive. That one didn't personally bother me, perhaps because I work in medical research and am used to there being lots of words and phrases that mean one thing to those in the field and something different to everyone else. But I appreciate that language is important and one phrase that I find really problematic is "normal birth".
For those who aren't familiar with the term, a "normal" birth as defined in the Birth Place study is a birth without induction, forceps, ventouse, caesarean, episiotomy or epidural, spinal or general anaesthetic I have a number of issues with that:
If This Is Normal - What Is Abnormal?
The main problem is, if you declare that a birth is only normal if it meets a strict and specific set of criteria then, by default, any birth that falls outside those criteria is not normal, it is therefore abnormal. Clearly forceps and epidurals etc are not natural parts of birth but are they really abnormal? I find this hardest to reconcile where pain relief is concerned. As I've said many times on this blog, I see nothing inherently wrong with making an informed decision to want pharmacological pain relief in labour. For many women, giving birth is extremely painful and I struggle to understand how wanting pain relief for something very painful is an abnormal action.
Normal also implies that this is how the majority of births happen, i.e. how the majority of women give birth. Telling people that "that's what everyone else does" is a powerful way to influence their decisions and one that is utalised by advertisers and government agencies. For example, it may be more effective to tell people that most others in their area have already done their tax returns, than to just threaten individuals with fines if they don't. Suggesting to women that most other mothers, normal mothers, have unmedicated vaginal births applies subtle pressure on them to conform to this ideal.
Is "Normal" actually Normal?
I'm not even sure if most women are having "normal" births. If anyone has better stats on this please let me know but going on the Birth Place Study data it seems like "normal" births aren't the clear majority. It found that for every 1000 low risk births in hospital, only 460 will be classed as normal. The majority of those planning homebirths do achieve the "normal" classification but that is still relatively few women so may not do much to alter the national average and, significantly, this data excludes all high risk births, which are presumably more likely to involve drugs or interventions. Essentially as far as I can tell, "normal" birth, isn't actually the norm.
***Update - many thanks to BirthChoiceUK who have confirmed that for England only around 40% of births meet the Birth Place Study definition of normal.***
What Is Normal Anyway?
Finally, I wonder about the criteria for normal. I can appreciate that syntocinon drips, instrumental deliveries and emergency caesareans should only happen in the event of medical need, ie. when something unexpected / not normal has happened. But then I come back to the pain relief issue. Why is it abnormal to have have a well researched and highly effective form of pain relief with known, minimal side effects (an epidural) but it's entirely "normal" to strap a small electronic device to your back and get it to give you regular electric shocks, even though there is little evidence that it's actually effective (a TENS machine)? Similarly if a "normal" birth is one that avoids any modern interventions why is it "normal" to labour and/or give birth in a recently invented, specialised pool of warm water? I'm not saying there is anything wrong with waterbirth by the way, I spent hours in the pool during my first labour and found it very helpful and calming, but clearly for most of human history women didn't have access to large quantities of clean warm water. Finally (actually I'm sure there are more but I think you get my drift) why is it abnormal for a birth to involve surgical incisions in the abdomen but a vaginal birth that results in the mother needing stitches, or even surgery under general anesthetic is still "normal"?
Of course sitting here and criticising from the comfort of my own blog is easy enough, I have no better word than "normal" for the type of birth described. I slightly prefer "natural" as normal birth is essentialy that - a birth which needs no help from modern medicine, and personally I would rather be unnatural than abnormal. But I appreciate that natural comes with it's own problematic connotations.
But do we even need a word to classify this? Doing so, and placing the emphasis on getting more women to have this particular kind of birth worries me. What about those who can't meet this standard due to medical reasons? What about those who can't or don't want to endure the pain? It seems to me worryingly patriarchal to hold up one kind of birth as the ideal for all women at a time in our history when there have never been so many good, safe, options available. I am all for supporting women who want this kind of birth but I worry about just where support and encouragement turn into persuasion and coercion.
For me, "normal" is a mother who wants to ensure the well being of her baby and who will make huge personal sacrifices to achieve that. Whether that means enduring the pain of a natural birth, the risks and indignities of interventions or the arduous recovery from a C section. There are so many different kinds of birth, none is inherently better or more valuable than the others, and none can claim the title "normal" by shear weight of numbers. The only thing that is genuinely Normal about birth is the everyday, ordinary heroism of mothers everywhere, bringing their babies into the world the best way they can.