Summary of the impact

Our theoretical and empirical work in the area of normal childbirth and associated cultural and contextual issues has been cited in two NICE guidelines, in professional body standards, and national consumer group websites (AIMS, NCT, BirthChoiceUK). One study provided the catalyst for the UK's Normal Birth Campaign (http://www.rcmnormalbirth.org.uk/ and international successors, and influenced the definition of normal birth in UK National Statistics. The programme has generated: significant media coverage; an EU funded network including 26 countries that is influencing the international normal birth debate; recognition as international change agents in this area (http://econpapers.repec.org/paper/emnwpaper/023.htm, leading to the award of an OBE.

Underpinning research

Key insights

There has been a global critique of the so-called medicalisation of childbirth since the 1970's. The ReaCH (Research in Childbirth and Health) team have significantly influenced an alternative, more positive research dialogue around which contexts, behaviours, attitudes and techniques might maximise physiological, salutogenic childbirth.

What research, undertaken when and by whom

Since 1994, Soo Downe has been working in the area of normal physiological labour and birth (over 60 publications to date). In 2001, with professional and service user co-researchers, she undertook the first study in the world that showed, empirically, high levels of routine interventions during so-called `normal childbirth' (the Trent Study, Downe et al 2001).

With an Egyptian colleague, she subsequently published an ethnography of an Egyptian labour ward (elNemer et al 2006). This illustrated that unnecessary childbirth intervention was not restricted to high-income countries.

Examination of the cultural context of childbirth has included in-depth qualitative studies, and systematic reviews (Walsh and Downe 2004, and the current Cochrane review of alternative settings for birth, Hodnett et al 2012). Studies of clinical techniques for maximising physiological processes have included an RCT of different positions for women using epidural analgesia in labour (Downe et al 2004). An EU COST network grant led by Downe (IS0907) is designed to examine optimum organisation for salutogenic birth, and has 26 countries in membership (435,000 euros, 2010-2014). Downe is also PI on an NIHR RfPB funded RCT designed to test the effect of self-hypnosis on use of epidural analgesia in labour (the SHIP Trial, £318,155). The trial has generated extensive print, radio and social media coverage locally, regionally, nationally and internationally. Funding has been obtained to support clinical staff; for example Jo Hollerans work that examines the effect of labour ward computerisation (Wellbeing of Women, £20,000) and public and professional bodies have funded associated activities (CEMACH; systematic reviews of why women don't use antenatal care, and RCM, repeat of the Trent Study, £30,000). Team members are named co-investigators on three relevant themes of the new NIHR CLAHRC NW Coast programme (approximately £3.500.000)

Maximising physiological birth as far as possible for women and babies where labour and birth are not straightforward is also part of our programme, based on our concept of `unique normality'. For example, most pregnant women state that they would prefer a normal birth. There is, therefore, interest in why some women apparently choose caesarean section. Carol Kingdon has ten publications in this area, one of which generated significant professional, media and public interest (Kingdon et al 2009). Our study of families who experience the tragedy of stillbirth has resulted in three publications to date. The most recent addresses ways of making the birth experience as positive as possible (Downe et al, 2013).

References to the research

Details of the impact

Note: numbers in superscript refer to the evidence cited in section 5 below

1. Our work has been crucial in reframing understanding of normal birth for professional, governmental and service user organisations

Our programme of work, and specifically the Trent study, was catalytic in changing the UK definition of normal birth. A recent EU review of the importance of knowledge creation in childbirth activism in Europe¹ has stated:

`... it was a small number of childbirth activists (Beverley Beech, Soo Downe, and Miranda Dodwell)... who were arguably the key architects of the normal birth agenda, feeding statistical and conceptual knowledge into the MCWP's [the national Maternity Care Working Party] activities, and strongly influencing the NCT's [National Childbirth Trust] position on these....(p10)

The report goes on to demonstrate how the UK definition of normal birth was developed, and how it was taken up in the EU Peristat on routine data collection for maternity care, and cites: ...'

`beginning to have routine data on normal birth also helped give... something real....something you could measure....that was really important.' (p12).

Soo Downe was awarded an OBE for services to midwifery in 2011, partly in recognition of this activity.

2. National guidelines groups have included our research in their reviews The current NICE Intrapartum guideline² cites two of our studies (refs 47, 176). The NICE CS guideline cites two separate studies³ Both guidelines are central to practice in the UK, and are used internationally.
3. Practitioners/professionals have used our research findings in conducting their work, nationally and internationally The UK Royal College of Midwives Campaign for Normal birth⁴ was catalysed by our Trent study. Soo Downe was the founding Chair of the Campaign, which is focused on midwives and on the need for the midwifery profession to refocus on salutogenic approaches to normalising childbirth. The Campaign has produced ten top tips to maximise positive physiological birth that are widely used by practitioners. These have been translated into ten other languages so far, based on requests from overseas practitioners.
4. Voluntary groups have both influenced and been influenced by our research. As noted above, the definition of normal birth used by our seminal study published in 2001 was based on that proposed by AIMS, a service user group. Recently, we have been funded by the Stillbirth and Neonatal Death society (SANDS) to undertake a number of studies designed to improve care in this area. The findings are reported on the SANDS website⁵, with plans to use them to influence more positive, relationship based intrapartum care by professionals who encounter parents who experience stillbirth.
5. Our work has influenced international professional policy debate. There are a number of international Normal Birth Campaigns (for example, in Portugal⁶) that are directly based on the RCM Campaign for Normal Birth Our theories of saltutogenesis and complexity and of positive relationship-based care underpin the iR4B EU COST programme⁷ that we lead which is designed to bring all maternity care up to the best standards in 21 countries in Europe, and China, South Africa, Australia and Israel.
6. National and international public awareness of the benefit of positive, relational based solutions for maternity care has been catalysed by the extensive local, national and international media coverage⁸ of our ongoing study of self-hypnosis for labour pain (SHIP trial), by media interest in Carol Kingdons work around womens choice for caesarean section, and by a DVD designed and produced by Downe and Byrom, funded by the RCM, available on the RCM website, and on YouTube.
7. Our research and philosophical approach has influenced professional training for national and international practitioners through a face to face and distance learning Masters modules for practitioners, that attracts up to 20 people each time it is run. Most of these people are leaders in their fields locally. These modules are based on our research, and that of others working in the field. Feedback from students regularly reports changes in personal beliefs and practices in relation to normal childbirth as a result of attending the module⁹.
8. Our international normal birth conference series is attended by up to 200 practitioners, policy makers, and researchers annually. It has been run successfully in the UK, China, and Canada, and will take place in Brazil in 2014, when up to 1000 attendees are expected. As for the normal birth module, feedback consistently highlights changes in beliefs, and intention to make practice changes among delegates¹⁰.

Sources to corroborate the impact

1. Akrich M, Leane M, Roberts C and Nunes JA 2012 2028 Practising childbirth activism: a politics of evidence No 23, CSI Working Papers Series from Centre de Sociologie de l'Innovation (CSI), Mines ParisTech Available from: http://econpapers.repec.org/paper/emnwpaper/023.htm
2. NICE intrapartum care (guideline 55) 2007:
   http://guidance.nice.org.uk/CG55/Guidance/pdf/English. (References no 47, 176)
3. NICE Clinical Guideline Caesarean Section (CG 132) November 2011 p.161 of Evidence Tables http://www.nice.org.uk/nicemedia/live/13620/57165/57165.pdf
4. Campaign for Normal birth: (http://www.rcmnormalbirth.org.uk/, http://www.rcmnormalbirth.org.uk/about-the-campaign/definitions-and-the-rcm-position-paper/).;
5. SANDS website: information about postmortem, and qualitative study of parents views and experiences of intrapartum care: http://www.uk-sands.org/improving-care/information-for-health- professionals/sands-position-statements/post-mortem-consent-after-a-late-miscarriage-stillbirth-or-neonatal-death.html and http://www.uk-sands.org/research/research-projects/post-mortem.html
6. Portuguese government paper on the need to normalise childbirth (see citation, Kingdon, page 92):
   http://www.msc.es/organizacion/sns/planCalidadSNS/pdf/equidad/estrategiaPartoEnero2008.pdf
7. EU COST Action: Childbirth Cultures, Concerns, and Consequences: Creating a dynamic EU framework for optimal maternity care (iResearch4Birth): iR4B website:
   http://www.iresearch4birth.eu/iResearch4Birth/ and official website:
   http://www.cost.esf.org/domains_actions/isch/Actions/IS0907 Lead researcher: Downe. Funding: 400,000 euros
8. Media references Attention following publication of paper in BJOG (Kingdon et al, 2009) included articles in print copies of two national newspapers (the Daily Telegraph
   http://www.telegraph.co.uk/health/healthnews/5193765/Women-do-not-choose-Caesareans-as- too-posh-to-push.html; The Irish News), published statements from the the Department of Health, General Secretary of the Royal College of Midwives and the Editor-in-Chief of BJOG, and worldwide web coverage on professional medical, nursing, midwifery (i.e.
   http://www.rcog.org.uk/news/bjog-release-women-value-safety-over-choice;
   http://www.nursingtimes.net/women-change-birth-preferences-throughout-their-pregnancy- according-to-study/5000764.article), and women's interest sites
   (http://www.marieclaire.co.uk/news/health/317280/majority-of-women-choose-natural-birth.html; http://www.askbaby.com/elective-caesareans-a-small-proportion-of-births.htm

SHIP Trial: media coverage in Sunday Times, Telegraph, Daily Mail, local and national radio, UK and international blog and social media sites: see for example:
http://www.dailymail.co.uk/health/article-1356592/Mothers-taught-hypnotise-giving-birth-NHS- trial.html

Midwives Work DVD: http://www.youtube.com/watch?v=_NRfU3NRW_Y
9. Downe S 2010 Beyond evidence-based medicine: complexity, and stories of maternity care. Journal of Evaluation in Clinical Practice 16 (1) 232-237
10. Normal birth conference flyers and testimonials:
    http://www.iresearch4birth.eu/iResearch4Birth/resources/cms/documents/China_English_flyer.pdf

http://www.rcm.org.uk/college/your-career/students/student-life-e-newsletter/student-life-july-2011/normal-labour-and-birth-sixth-international-conference/

www.rcm.org.uk/EasySiteWeb/GatewayLink.aspx?alId=153951

http://midwifery.ubc.ca/research/research-activities/normal-labour-birth-research-conference/