1.2 Background

The first issue to be clarified is the sense in which the expression “normal birth” is used throughout this paper (see 1.4 below). It is vital to be specific on this if misinterpretation is to be avoided. A frequently cited statement concludes that “childbirth can only be declared normal in retrospect”. This widespread notion led obstetricians in many countries to conclude that care during normal childbirth should be similar to the care in complicated deliveries. This concept has several disadvantages: it has the potential to turn a normal physiological event into a medical procedure; it interferes with the freedom of women to experience the birth of their children in their own way, in the place of their own choice; it leads to unnecessary interventions; and, because of the need for economies of scale, its application requires a concentration of large numbers of labouring women in technically well-equipped hospitals with the concomitant costs.

With the global phenomenon of increasing urbanisation many more women are delivering in obstetric facilities, whether they are having normal or complicated births. There is a temptation to treat all births routinely with the same high level of intervention required by those who experience complications. This, unfortunately, has a wide range of negative effects, some of them with serious implications. They range from the sheer cost of time, training and equipment demanded by many of the methods used, to the fact that many women may be deterred from seeking the care they need because they are concerned about the high level of intervention. Women and their babies can be harmed by unnecessary practices. Staff in referral facilities can become dysfunctional if their capacity to care for very sick women who need all their attention and expertise is swamped by the sheer number of normal births which present themselves. In their turn, such normal births are frequently managed with “standardised protocols” which only find their justification in the care of women with childbirth complications.

This report is not a plea for any particular setting for birth, for it recognises the reality of a range of appropriate places, from home to tertiary referral centre, depending on availability and need. It simply aims to identify what constitutes sound care for normal birth, wherever that birth takes place. The point of departure for the safe achievement of any birth, the assessment of risk, requires a special study of its own, but a brief introduction to the concept is needed here before the components of care in labour are discussed.