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What is the Meaning of Normal Birth?

[Editor’s Note: This marks the beginning of our coverage of the 5th International Normal Labour & Birth Research Conference, taking place July 20-23 in Vancouver. Sharon Dalrymple, staff development nurse, prenatal educator, doula, and Lamaze’s first Canadian president, will present a session she developed with maternity care quality expert and Lamaze’s president-elect, Debra Bingham. They were both part of a research team that investigated how women perceive terms like “normal birth” and “natural birth” and what that means for helping them understand evidence-based information to make health and healthcare choices. There are many reasons that women’s perceptions and priorities matter in birth. One is that meaningful improvements in maternity care quality and safety are impossible without a strong consumer movement. Dalrymple’s and Bingham’s findings have major significance for “normal birth,” however we each define it.

Remember, there’s an Open Thread for conference attendees and enthusiasts to post messages. You can follow all of the updates from the conference on Twitter by following the #birthconf hashtag and find more analysis here on the blog – AMR]

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For the past 50 years Lamaze International has been promoting normal birth practices in North America and more recently worldwide. Despite these educational efforts women are being over-treated more now than they have been in over 30 years. For example, 31% of women in the United States give birth by cesarean surgery. The overuse of interventions with harmful side effects when there is little or no expected benefit for mother or baby has led to worsening maternity care outcomes in the United States and many other countries. In addition, women do not get adequate information so they are aware of the excess, unnecessary risks they and their infants are being exposed to.

One of the reasons these educational efforts may not have been as effective as desired is that our conversations may not be persuasive enough or clear enough. For example, it is not universally understood or agreed upon how to define a normal birth, the differences between normal and natural birth, and which behaviors constitute a normal birth. Conversations and language affect how persuaded others are to make changes. In fact, 50 years of diffusion of innovation research tell us that for women to demand safe, high quality maternity care, we must engage in clear conversations that outline specific desirable behavior changes and show that women and babies can expect better health outcomes if these changes are made.

Lamaze International hired a public relations market research firm to conduct research and identify which messages are the most effective for persuading women to adopt normal birth practices. Online surveys were conducted among 811 women aged 16-44  and 408 Lamaze Certified Childbirth Educators.

Indeed, the research showed that the meaning of the words “normal” and “natural” was not interpreted by the women and educators the same way. For example, 36% of women felt that ALL vaginal births are “normal birth”, while 63% of Lamaze Certified Childbirth Educators defined “normal birth” to be a birth without medical intervention. Women and Lamaze childbirth educators are likewise divided when deciding if the terms “natural birth” and “normal birth” are generally similar or generally different in meaning.

Lamaze International found that the words safe and healthy are the most effective words for communicating and promoting the birth practices Lamaze has endorsed for years. Everyone wants a safe and healthy birth. Mothers are particularly motivated to keep their baby and themselves safe and healthy. Most importantly, the practices are safe and healthy.

As a result of these and other findings, Lamaze International updated our six evidence-based key practice papers in Fall 2009 to ensure women realize that these practices simplify the birth process with a natural approach that helps alleviate fears and manage pain, with the ultimate goal of keeping labor and birth as safe and healthy as possible for each individual woman. Every woman needs clinicians who promote, support, and protect these six practices:

1. Let labor begin on its own

2. Walk, move around and change positions throughout labor

3. Bring a loved one, friend or doula for continuous support

4. Avoid interventions that are not medically necessary

5. Avoid giving birth on your back and follow your body’s urges to push

6. Keep mother and baby together – It’s best for mother, baby and breastfeeding

Conflict of Interest Disclosure: The research was funded by Lamaze International.

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  1. avatar
    km
    July 19th, 2010 at 09:43 | #1

    I just wanted to point out –

    I gave birth in a hospital with an OB, and will again. And points 1-6 EXACTLY describe my birth. So, while I respect those who want to understand/stay involved in the decisions, I hope that those of you who advocate for women don’t forget that hospitals and doctors are good places for many (if not most!) women, and that a choice to select one should not be denigrated, looked down upon, or discouraged.

  2. July 19th, 2010 at 15:49 | #2

    It seems like it would be important to establish some kind of baseline lest it be established for you. We’ve all seen how fear of litigation, desire to control the unpredictable and the desire for profit and efficiency have affected the way women give birth in the U.S. and beyond.

    Check out this post on Sociological Images: http://contexts.org/socimages/2010/07/08/norms-normality-and-normativity/

    What I see Lamaze trying to do is establish a norm from which women can “opt in” to other labor interventions as desired, rather than have a cookie cutter process from which they start out with an oppositional stance by opting out.

    I’m sure you’re anticipating comments in which people complain about the word “normal” because, rather than see it as trying to establish a judgment-free norm, they can’t see it as anything but the opposite of abnormal (with perceived judgment) or choose to see anything Lamaze does as promoting a morally-endorsed ideal (normative).

    If there is something normative involved, it has more to do with imploring care providers to behave differently and support women in giving birth ______ (upright if desired, without an epidural, with lots of social support, whatever). The care provider attitude that whatever they do is necessary and the normative normal norm (ha) is hard to shift.

    So good luck with that. When people can’t complain about anything substantial, they’ll usually complain about semantics.

  3. July 19th, 2010 at 15:55 | #3

    By the way, I’m glad you wrote about this, Sharon. I’ve met lots of people in the last few years who DO seem to view unmedicated vaginal birth as a moral and biological imperative. It doesn’t always click until I realize they’re talking about things as if it’s something every woman should do, rather than as something every woman should have the option to do. Huge difference.

  4. July 19th, 2010 at 19:49 | #4

    The word “normal” takes on an enormous charge when applied to childbirth that it does not seem to have when applied to other physiologic functions. Nobody thinks a thing about it if we talk about “normal digestion” or “normal breathing,” or, for that matter, “abnormal” digestion or breathing. My theory is that this is because childbirth is so intimately connected with our female and sexual identities. “Normal” when used to describe labor and birth loses its neutrality and becomes a judgment.

  5. July 21st, 2010 at 16:52 | #5

    Why does there need to be a “normal” birth at all? Given that about 1/3 of women in this country now delivery by cesarean section, it is hard to say that this is not part of what is now normal in this country. We can argue whether or not this is optimal for women, but it certainly is part of what is normal now.

    I agree with Henci that the use of the word “normal” is usually a value judgement that doesn’t help anybody. Even the term “natural birth” has no clear meaning, and is also frequently used in a judgemental way. It may be natural to avoid interventions, but its also natural for some women and babies to die in childbirth and in complications of pregnancy. Folks that use “natural” to mean a superior way of delivering a baby don’t tend to look at that part of nature.

    Women come from such different backgrounds and have very different expectations of birth. We should just provide what each woman needs and wants, while doing everything we can to have good outcomes. Labeling any particular course “normal” or “natural” or “unnatural” or “medical” does no one any good.

  6. avatar
    Michaela
    July 23rd, 2010 at 08:24 | #6

    As a woman who is going to give birth for the first time in a few days, I feel obligated to weigh in on this. I live in RI near a wonderful hospital where some 80% of women get epidurals. (I will be using the “alternative” birthing center, speaking of semantics!) None of my friends breastfed, ALL of them had epidurals, several of them ended up with c-sections for “failure to progress. They think that “natural” means vaginal. Good luck with your campaign!

  7. July 25th, 2010 at 10:59 | #7

    Wonderful post, Sharon. As always, it’s great to get back to the basics of defining the terms involved in a hot debate.

    The terms “normal” and “natural,” when paired with “childbirth,” have become so political and, yes, judgmental that they stopped being helpful in a childbirth education setting long ago. As Henci points out, when paired with other terms…breathing…heart rate…blood pressure…the judgment fades away.

    To me, this all comes down to education–as several here have mentioned, the misconception that vaginal birth equals “natural birth” is an education problem. I almost wonder if we could substitute the word “informed” for “normal” or “natural” and achieve an entirely different goal? And so, responding to Nicolas’ comment, “Women come from such different backgrounds and have very different expectations of birth. We should just provide what each woman needs and wants, while doing everything we can to have good outcomes,” I have to partly disagree. If women are inadequately informed about childbirth options, risks and benefits, and opt to hand over their childbirth process and experience to another person, should we really provide them that?

    Perhaps an (admittedly hollow) analogy would work well here:
    Suppose I inherited a multi-million dollar dream home that needed a little remodeling. What would I be more likely to do? Arrive on site and hand over the keys to whichever contractor showed up, saying, “Just do whatever you think is best.”? Or would I take a vested interest in the process, researching flooring, hardware and cabinetry options, etc., etc.?

    I dare suggest, in America we spend more time researching the cars, cameras and televisions we buy, than we do learn about the process of birthing our most valuable assets–our children.

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