Stop ‘scaring’ older mothers
Features As Cathy Warwick retires as Royal College of Midwives chief, she tells Rosa Silverman why there’s no right or wrong way to give birth
THE NHS should stop “terrifying” women about the risks of having babies later in life, Britain’s most senior midwife has said.
Prof Cathy Warwick, chief executive of the Royal College of Midwives, said health professionals had overstated the risks attached to age, putting older mothers through undue stress.
Births among older women have tripled in the last three decades, with more children now born to mothers over 40 than under 20. Older motherhood carries a higher chance of complications, disability and stillbirths.
But Prof Warwick said the risks were being overplayed. “Even if you have your baby at 42 or 45, it’s a relatively small increase in risk to you if you’re otherwise healthy,” said the midwife, who has stood down after nine years leading the RCM. “I’m not sure why we’re quite so worried about the age issue and I’m not sure we should be terrifying women about it,” she said in an interview with The Sunday Telegraph.
While women aged 30 to 34 have stillbirth rates of 4.7 per 1,000 pregnancies – similar to that for women in their late 20s – this rises to 7.6 per 1,000 pregnancies among women over 40.
The chance of abnormalities – such as Down’s syndrome – goes from 1 in 800 for a woman of 30, to 1 in 100 for a woman of 40, NHS statistics show.
Childbirth isn’t what it used to be. Yes, the key elements remain unaltered – the essential physiology, the mechanics, the emergence of a howling baby at the end of it all. But the process of getting from A (pregnant) to B (cradling your newborn) has undergone sweeping changes.
Few have borne witness to this more than Professor Cathy Warwick, the outgoing chief executive of the Royal College of Midwives (RCM), whose nine-year tenure at the helm of one of the world’s oldest and largest midwifery organisations ended on Friday.
Warwick, 65, a mother of three, is exactly the kind of person you would want at your labour: gentle but authoritative, a reassuring presence, even in a setting no more perilous than an upstairs meeting room at the RCM’s central London headquarters, where she faces me across a long table.
Originally from near North Berwick, she has retained her Scottish burr, despite the 41 years she has lived in London (the past 33 of them in the same house in Balham). After studying nursing at Edinburgh University, she completed a one-year midwifery course at Queen Charlotte’s Hospital in London in 1976 and has been in the business ever since.
If she’d hoped for a smooth exit, however, it was not to be: the eve of her departure was dominated by an unexpected furore over the RCM’s Normal Birth Campaign. Quietly dropped three years ago in favour of a broader Better Births Initiative, which “seeks to improve care for all women, including those with medical and obstetric complications”, the change of tack emerged last month when the RCM said it had removed a “top 10 tips for a normal birth” article from their website.
Experts said a “cult-like fixation” on “normal birth” by midwives – with doctors excluded from the delivery room, even when needed – had fuelled errors and record negligence claims, and a fierce debate raged. Warwick denied the campaign had compromised safety, but acknowledged it had “created the wrong idea”.
“The problem,” she tells me, “is if we create a situation where women feel there’s a right and a wrong about giving birth. There isn’t. Women should have the best birth possible for them. For some, it will be a normal birth in a pool at home, while for others it will be an elective caesarean section in an obstetric unit, and we can, if we do our jobs properly, make each of those experiences a good experience. I feel very unhappy when I hear women feel they’ve failed. I think that’s terrible.”
In a blog post on the issue, she promised the RCM would carefully examine the language it used in future. Of that contentious word “normal”, she said: “We know what it means, but for many it has a judgmental quality that we absolutely do not intend.”
More broadly speaking, what’s normal in childbirth has, in any case, shifted since the early years of Warwick’s career. Back then, the average woman would come into hospital and have their baby more or less in the manner they were told to. Today, we research every aspect at length, trawling through Mumsnet and the like to glean the pros and cons of a water birth, a TENS machine, a soundtrack of Burmese monks chanting…
“Now it’s like choosing schools,” says Warwick. “We’re very consumerist about it, as opposed to it just being something that happens.”
Many of these things are offered to us antenatally, and can be costly: the hypnobirthing course, the pregnancy yoga classes, the private ultrasound party – it all adds up. “I think women are exploited with all these offers,” says Warwick. “There’s not nearly enough [conversation] in our society about birth as a normal process.” But don’t we talk about it all the time? We have whole TV shows devoted to it.
“One Born Every Minute is a really tricky programme because it tends to dramatise birth in a way that’s not necessarily terribly helpful,” says Warwick. “On the other hand, Call the Midwife dramatises birth in a way it isn’t necessarily like now. There’s loads of chat about birth on the internet, but it’s not embedded in society like it used to be.”
As with any consumer experience, we now want a menu of options; we want to exert some control. Which is fine, until nature – or a health professional – overrules us. As Warwick points out, birth is inherently unpredictable.
“Quite rightly, women’s expectations are higher and women have more knowledge of what’s available,” she says. “So you get women who might desperately want a C-section, and women who desperately want a normal birth, and it wasn’t like that when I started off as a midwife. It potentially makes it very challenging for professionals, and it also can make it very challenging for women, who have much higher expectations about what’s going to happen.”
Not that they should be passive, merely accepting whatever is done to them, as remains the case in some countries. Those who feel they have had some control over their labour not only feel more ready to be mothers, but also to dictate other aspects of their lives, Warwick notes.
Her advice, then, to pregnant women would be to keep an open mind; to recognise that if things don’t go to plan, it doesn’t equate to failure.
The recent fuss over normal births is not the only controversy in which she has been caught up. In 2014, Warwick was criticised for leading the RCM out on strike for the first time in its 136-year history over a pay dispute. Last year, she faced demands for her resignation when the RCM supported a campaign to scrap the time limit on abortion.
“I prefer to negotiate than have conflict. But when I feel [something is] the right thing to do, I’m prepared to stand up and defend it,” she says.
Elsewhere, she is refreshingly sanguine. Women are routinely cautioned against waiting too long to start a family, but Warwick – who has seen the average age of first-time mothers rise significantly – shrugs off the dangers.
“Even if you have your baby at 42 or 45, it’s a relatively small increase in risk to you if you’re otherwise healthy. I’m not sure why we’re quite so worried about the age issue, and I’m not sure we should be terrifying women about it. The thing I feel sad about for women is if they leave childbearing later and then can’t conceive.”
Then there’s breastfeeding, that other stick with which women are so often beaten: we’re either doing it too flagrantly, or else not enough.
‘If women don’t breastfeed, I don’t think they should feel guilty’
Rates of breastfeeding in the UK are the worst in the world.
“The breast is still sexualised in a rather negative way,” reflects Warwick. “So there’s work to be done right from the beginning about educating kids, about making sure society supports breastfeeding.”
But she is clear it is not the be-all-and-end-all. “If women don’t breastfeed, I don’t think they should feel guilty. We have to say ‘breast is best’ because it is, but what’s best for the population is maybe different from what’s best for the individual woman, and an individual woman can very successfully bond with their baby and bottle-feed their baby.”
She is pleased to see fathers playing a more active role in the delivery room, but insists it is ultimately the woman’s experience. “I do have a slight problem with dads making it ‘their’ birth…” she says.
With retirement, she has other things to think about now; holidays with her husband, who formerly worked in the oil industry, to plan. Having already climbed all the Scottish Munros, she now wants to tackle the next mountain tier down, the Corbetts. Does she have any advice for her successor, Gill Walton, the former director of midwifery and maternity services at Portsmouth Hospitals who takes over from her tomorrow?
“There are times when you are doing the right thing and you will be criticised,” she says. “You have to have broad enough shoulders to carry that.”