Where’s the Evidence?
This page outlines the history and evidence related to GMAGs campaign, quoting from some excellent literature and highlighting key research that underpins our advocacy.
Here, we will explore:
The history of our birth culture and how we came to be where we are today
How incorrect assumptions on “risk” (obstetrics = safe, midwifery = risky) now drive decisions about women’s health
How Gloucestershire Health Overview & Scrutiny Committee (HOSC) - the body in place to hold decision makers accountable - is failing to genuinely scrutinize these assumptions
What the evidence actually shows, including:
Planned home birth and midwifery care are as safe or safer
CTG monitoring has never been shown to improve safety
Millions has been paid out, and continues to be paid out, for birth injury and trauma occurring within the medical system
And what there is no evidence to support, including:
The idea that “women are more complex and require more interventions now”
Caesarean-on-request is rising because this is what women want
Where evidence-based systems are already in place around the world, including the Netherlands, New Zealand, Ireland and Norway - delivering safer outcomes for women and babies.
The History of Birth
“We can only understand what happens to women during the childbirth right of passage by understanding birth culture and its historical roots.”
- Dr Rachel Reed, Reclaiming Childbirth as a Right of Passage.
How did our society get to this point?
“The history of the development of obstetrics is enmeshed with the social position of women during the last four hundred years. Until the 17th century in this country, birth took place amongst women. Women supported each other through labour and birth and men were excluded from this rite of passage. Knowledge was largely experiential, passed on between female friends and relatives. Often women became particularly knowledgeable about birth, because they had attended many in their local area, were the first midwives, when midwifery was not a profession.
By the 18th century there was a growth in scientific enquiry, particularly with regards to the human body, its physiology and anatomy. Women were not seen as men’s equals and were excluded from the type of knowledge that developed and from the profession that began to evolve. One of these professions was obstetrics.
Men began to enter the birthing room as man-midwives around the 18th century. With their entry also came the expectation that women give birth on their backs and the development of birthing equipment such as forceps. Places to birth began to move into institutions such as lying-in hospitals which in effect were the forerunner to modern maternity wards. With the exclusion of women from this developing profession, power over birth started to shift from female midwives to male obstetrics. Some people may think that the development of obstetrics was based on benevolent sentiments and for many practitioners it may well have been, However, it is also embedded within an era of overt sexism. A quote from the secretary of the Obstetrical Society in 1867 highlights the power dynamic between women and obstetricians at the time:
“...we have constituted ourselves, as it were, the guardians of the interests, and in many cases… the custodians of their honor… We are in fact the strong, they the weaker. They are obliged to believe all that we say to them, and we, therefore, may be said to have them at our mercy.” (Haden, 1867).
At the time, Victorian doctors and researchers (who were all men) had a bizarre understanding of the female body and the role of genitals and reproductive system to a woman’s health. In her book, The Female Malady, Elaine Showalter describes how some doctors advised putting leaches on menopausal women’s cervixes to prohibit sexual desire and clitoridectomies (surgical removal of the clitoris) were carried out as a cure for female insanity.
The development of some obstetric and gynaecological equipment also has an extremely dark history and reflects a society embedded in racism and misogyny. The speculum, which is still used today as a way of viewing the cervix, was based on an invention by James Marion Simms, an American who tested his design on enslaved black women during the nineteenth century (Marion Simms, 1884).
What this alludes to is a system that has grown from a society where the medical establishment treated women and their reproductive systems very harshly. What it does mean is that the foundations of the profession are less than ideal. It is hard to imagine these foundations have no effect on the system in which obstetricians now operate.”
- Safety in Childbirth, AIMS, pg.31-33
“The social and cultural climate was rapidly changing during the rise of the man midwife, and these changes add to the erosion of traditional female practice. Increasing industrialisation led to trades becoming separated from the home. MOst women were unable to work in these trades because of their responsibilities in the home. Women who could work in factories no longer attended births due to their work patterns. Over time, the collective culture of women at birth became unsustainable.
In England in the 1600s, men were still only employed to assist during complicated births. Male midwives capitalised on this by exaggerating the dangers of childbirth and denigrating the competence of female midwives. Before the new scientific philosophy, women had built up a body of female knowledge about childbirth, disseminated via their oral culture. This knowledge sat outside formal education from which they had historically been excluded. The shift towards book learning enabled men to publish medical texts that communicated their understanding of birth and further reinforced their authority in this area. Traditional female midwives faced difficulties articulating the nature of their knowledge. Their knowledge was less empirical, and they learned through apprenticeships and experience rather than books. When formal midwifery education was eventually introduced in the eighteenth century, it was based on the mechanistic understanding of birth created by men and led to the further suppression of traditional midwifery knowledge.”
- Dr Rachel Reed, Childbirth as a Right of Passage, pg. 19-20
“In a fascinating historical study of literature from New York in the early 1900s, Johnson and Quinlan (2015) demonstrate how midwives were becoming regulated and legislated alongside smear campaigns fuelled by physicians. Midwives' sphere of practice legally became limited to “natural” births and any necessity for medicine or instruments became the legal domain of obstetricians (Yam, 2020). Obstetricians promoted birth in a controlled, hospital setting and middle and upper class women were lured with the promise of medicinal pain relief for a fee (Johnson & Quinlan, 2015). Obstetricians experimented with a range of medications under the belief that it was their duty to relieve pain. The long-term outcomes for women and babies were unclear and experimental medications included paraldehyde, chloroform, cocaine, heroin, and scopolamine (called twilight sleep) (Eley et al., 2015, Johnson & Quin, 2015).
By the beginning of the second wave of feminism, most women in high resourced countries were birthing in hospitals managed by obstetricians. In opposition to the advancing medicalisation of birth, women wished to take back control and embraced a natural birth movement, one where women were aware of their birthing experience (not in an amnesic and sedated state) and learnt distraction and breathing techniques to cope with labour. The impact of this was starting to be felt and activists and feminist scholars were starting to take notice.
Yet obstetric power remained throughout the 1970s and 1980s. The impact of obstetric management continued to be questioned, considering the evidence of rising caesarean rates. In 1993, Ann Oakley published her book Essays on Women, Medicine and Health, where she wrote;
“What does it do to women to have their babies gestated and born very much within such a closed structure of medical surveillance? It is hard to feel in control of one’s body and ones destiny during sixteen trips to the hospital antenatal clinic for the ritual laying on of hands by a succession of different doctors, none of them especially trained in the art of talking to faces beyond abdomens, or in the science of knowing about the interaction between mind and body, the connection between peace of mind and a competent cervix, or between emotional confidence and coordinated uterus. What we see involved here are issues of control and responsibility that come up again and again in looking at women's health” (Oakley, 1993, ph.12-13).
Ann Oakley identified how the dominant position of obstetricians resulted in the paternalistic belief that pregnancy and childbirth was a pathological process with the focus on the end product of the baby (Oakley, 1993). Brigitte Jordan name this "authoritative knowledge” which she described as: “...the knowledge with within a community is considered legitimate, consequential, official, worthy of discussion and appropriate for justifying particular actions by people engaged in accomplishing a task at hand” (Jordan, 1997, p.58). Basically, the popular belief from both within hospitals at large was that the medical establishment was right and safe, and the “at least you have a healthy baby” attitude prevailed. How women felt about their birthing experience was not seen as important or addressed as the woman did not hold any useful knowledge and it was of no consequence (Jordan, 1997).
American anthropologist Robbie Davis-Floyd named the medicalised obstetric model of care “the technocratic model of birth”, which she described as:
“In accordance with this metaphor, a woman's reproductive tract is treated like a birthing machine by skilled technicians working under semi-flexible timetables to meet production and quality control demands… The hospital itself is a highly sophisticated technological factory (the more technology a hospital has to offer, the better it is considered to be). As an institution it constitutes a more significant social unit than the individual or the family, so the birth process should confirm more to institutional than personal needs. Through these procedures the natural process of birth is deconstructed into identifiable segments, then reconstructed as a mechanical process. Birth is thereby made to appear as though it confirms, instead of challenges, the technocratic model of reality upon which our society is based” (David-Floyd, 1993, pg.278, 280, 281)
This could have been written today instead of 28 years ago. Policies and guidelines are written and developed by the colleges and hospitals that govern the practice. Women are expected to follow them and not have individual wishes. The mainstream obstetric management of pregnancy and birth has not changed dramatically in that time. What has increased is the caesarean rate.
- Birth After Cesarean Birth, Dr Hazel Keedle, pg 52 - 57
Today, in Gloucestershire and the UK, maternity care provision is built on a single, unexamined assumption: Obstetric = safe, Midwife-led = risky. However, no evidence exists to support this assumption.
Concerningly, our Gloucestershire Health Overview & Scrutiny Committee (HOSC) - the body in place to democratically scrutinize the Trust’s decisions - is failing to do so, with no question of what is mean by “safety”. As a result, a blind belief that more obstetric involvement in birth is safer for women and babies is now shaping decisions inside Gloucestershire Hospitals Trust.
Safety in Childbirth, AIMs, 2022, explores the concept of safety and risk in the broader sense of the individuals providing care in the NHS context:
The environment in which midwives and doctors work is often not ideal. Often budgets are cut, staff are overworked, and resources are limited. Policies and guidelines can be prescriptive and provide little room for a midwife or doctor to exercise independent professional judgement. This can result in a maternity system where midwives and doctors feel safest adhering strictly to guidelines, and refusing to challenge accepted practice and policy in support of the decisions or human rights of the pregnant woman or person.
We also live in a litigious society. In 2012-2013, for example, a third of the NHS clinical negligence bill for England stemmed from maternity care and nearly a fifth of all spending for maternity services was for clinical negligence cover (National Audit Office, 2013). Fear of litigation is very real within the NHS and it would be difficult for any midwife or doctor to work in such an environment without it impacting the way they practice.
A culture of blame usually goes hand in hand with a fear of litigation. In the work environment, this suggests a lack of support for employees. Nobody wants to be reprimanded by their manager. No midwife or obstetrician want to defend their decisions before the Nursing and Midwifery Council or the General Medical Council. So, while a clinical decision may not therefore result in a healthcare professional considering their physical safety, it may include them considering the safety of their jobs, their careers and their reputations. Any disciplinary or legal proceedings carried out against a midwife or doctor may also have a significant impact on their mental health and financial circumstances (see for example, Dahlen and Hunter, 2020).
A consequence of all this can be a system that fails to support pregnant women and people who make birthing decisions who do not align with the general policy and practice, a system that is not adapted to an individual's needs or decisions. Examples may include homebirths, breech vaginal births, births on midwifery-led units, waterbirths or freebirths. If a person decides to have a homebirth of twins, which would be considered “high risk” in the current maternity environment, a midwife may be reluctant to attend such a birth. Even if they are supportive, they may experience considerable pressure from colleagues to talk the pregnant woman or person out of such a decision. The midwife’s professional future and the NHS system taking priority over what women and pregnant people consider safe is unacceptable.
- Safety in Childbirth, AIMs, 2022, pg. 12-13.
Therefore, the provision, policies and guidelines determined have a huge impact on the care received, and when these are based more on unfunded assumptions rather than best available evidence, it puts women, babies and families at risk.
What does the evidence actually show?
Planned home birth and midwife-led care are as safe or safer
The data is remarkably consistent across decades, countries, and systems:
Babies do just as well — and in some datasets better — in planned home and midwife-led settings. Women have dramatically better outcomes, they have fewer:
caesareans
forceps/ventouse
episiotomies
infections
inductions and augmentations
Women report far higher satisfaction, lower trauma and faster recovery.
(and when we refer to satisfaction - it isn’t that women are putting a fluffy experience over safety. They mean that they are respected, and central to decisions and feel things are done with them, not to them)
Key studies:
• Birthplace in England National Study (2011)
• Cochrane Review: Midwife-Led Continuity Models (Sandall et al., 2016)
• Dutch National Cohort Studies
• Planned Home Birth vs Hospital – multiple international datasets
If you remove medical ideology and looked solely at outcomes, midwife-led care would be the backbone of Gloucestershire’s maternity system.
“In the 1950s, about 30% of women gave birth at home in England and Wales, but by the 1980s this had dropped to about 1% of women. This was a deliberate policy based on the assumption that hospital birth was the safest option for women and their babies.
In 1975, research statistician Marjorie Tew was teaching her students about how much information could be gained from analysing official statistics. To her surprise, she discovered that those statistics comparing outcomes of hospital and homebirths did not support the argument that increasing hospital birth rates had brought about a decline in the number of deaths of mothers and babies. Marjorie pursued her research and concluded that women who gave birth at home had a lower risk of their baby dying than those giving birth in hospital, and published her findings as long ago as 1980.
Although her statistical work on the relative safety of childbirth largely used data from 1970, her findings are still relevant today. The Birthplace in England research study published in 2017 shows that for women at low risk of complications, planning birth at home is generally very safe, and even safer for women having a second or subsequent baby. In addition, women are more likely to have a normal birth and to avoid medical interventions that may have long term consequences affecting future pregnancies and babies. NICE guidelines recommend that women are offered the choice of home or hospital birth. Planning a birth out of hospital and away from the likelihood of obstetric intervention is a valid and responsible choice”.
- Safety in Childbirth, AIMs, 2022, pg. 2-3.
“The majority of obstetricians, everywhere, have become so convinced that the natural process of birth is fraught with dangers which their increasingly sophisticated technological interventions are increasingly capable of minimizing. Amazingly, they have managed, without producing any valid supporting evidence, to persuade the majority of people, medical and lay, they they are right and the maternity service has been organized in accordance with this unjustifiable hypothesis” (Tew, 1986:671).
CTG monitoring has never been shown to improve safety
Continuous CTG monitoring — the symbol of “safety” — has never been shown to improve safety. This matters, because CTG monitoring is routinely used as the justification for pushing women into obstetric units, and the Trust repeatedly frames CTG and similar interventions as the solution to “risk”.
But the evidence could not be clearer. Its has been 40 years since the publication of the landmark Dublin Randomised Controlled Trial — the biggest and most rigorous CTG study ever conducted.
Study: MacDonald et al., NEJM 1985, Follow-up: 1989 https://pubmed.ncbi.nlm.nih.gov/3893132/
What did the trial find?
CTG monitoring did not reduce:
• stillbirths
• neonatal deaths
• low Apgar scores
• need for resuscitation
• NICU admission
• long-term developmental problems
Nothing improved.
What did increase?
Caesareans and instrumental births.
In other words:
CTG made outcomes worse for women and didn’t improve them for babies.This should have ended routine CTG use in the 1980s. Instead, CTG has been mythologised as “safety equipment”, and it drives a cascade of unnecessary interventions.
Yet this assumption — disproven four decades ago — is still guiding decisions in Gloucestershire today.
“Women are more complex, and need more interventions now'“— a claim with no evidence behind it
Claims about “women being more complex now” are repeated in meetings and reports, but no evidence has been provided to support them. Even where some comorbidities are increasing slightly, this does not justify blanket risk decisions or funneling women into obstetric care.
A higher BMI, a previous caesarean, mild hypertension, or being over 35 does not automatically make birth dangerous — and the research shows many of these women have better outcomes with continuity-of-carer and midwife-led pathways.
What is driving the rise in interventions is NOT women. And NOT safety. It is the system.
Unnecessary inductions.
Routine CTG.
Fear-based decision-making.
Loss of continuity.
Defensive practice.
Institutional anxiety.
These are iatrogenic complications — harms caused by the model of care itself. Midwife-led models (including home birth) are repeatedly shown to be safe for a broad range of women, including those with previous caesareans, when care is relational, continuous and non-interventionist.
Calling women ‘more complex’ while providing no data simply disguises the real source of rising interventions: the culture, practices and fear within obstetric units — not women’s bodies.
“Too often, pregnant women are told that, because they are above a certain age or size, they and their baby are more “at risk” and therefore need labour induction. Women who conceive by IVF or other assisted reproductive technologies are also perceived to be at higher risk. There are many women who are older and larger than average (in part because we tend to put on weight as we age), who may be told they are doubly or triply “at risk”, with no good evidence.
“I had to fight tooth and nail to not be induced, and I'm not exaggerating. I was 45, but really healthy. Baby was healthy too. They kept referring to me as “geriatric”. I did go into labour myself, Not at home as I would have wanted but it was alright and there weren't any problems. But the attitudes and assumptions were shocking. If I spoke to people like that in my job I would be sacked. I was told I was going to be indeed on his due date. Not asked. I’m so grateful to him for coming early as I didn't have the energy to fight and I don't know what I would have done. Probably just stayed home and turned the phone off. When I heard what they’re planning to do to other Black women in the name of risk management, I’m incensed.” - Adaobi.
Adaobi was responding to the suggestion of NICE (2021a) that induction at 39 weeks should be considered for all women who are Black, Brown, Asian or of mixed race. This proposed recommendation was greeted with considerable concern by women, midwives and birth workers. The final version of NICE guidelines (2021b) recommends that clinicians “Be aware that… women from some minority ethnic backgrounds or who live in deprived areas have an increased risk of stillbirth and may need closer monitoring and additional support”. When something becomes the norm, it can be particularly challenging for those who have less power, who don't understand the system, who don't speak english or who aren't always listened to.”
- Dr Sara Wickham, In Your Own Time, pg. 130-131
Caesarean-on-request the real issue
NHS Gloucestershire Trust repeatedly suggests that rising caesarean rates are due to maternal requests.
However, this suggestion completely overlooks the underlying reasons a woman may opt for major abdominal surgery. Many women requesting caesarean do so because of trauma,
fear, or prior poor treatment — not medical risk.
Good questions that the Gloucestershire Health Overview & Scrutiny Committee (HOSC) could have asked when the issue was raised in the 14th October meeting include:
What percentage does this account for of the 50% total caesarean rate
What support do they receive?
Could continuity of care reduce this number?
Could a midwife-led setting keep her emotionally and physically safer?
Did the system create trauma it is now treating as “complexity”?
But instead, the debate slides into a simplistic binary non-evidence based, incorrect assumption: Obstetric = more safety. Midwifery = risk. And women lose access to the very care that would have prevented their trauma in the first place.
The UK Government’s 2023 research on UK-wide birth trauma found that…
79% of women experienced birth trauma
53% experienced physical trauma
71% experienced psychological or emotional trauma
72% said their trauma lasted over a year or was still ongoing
More than half (53%) said they are less likely to have more children because of their experience.
And that leads directly to the part no one talks about: £20 million paid out for birth injury since 2020
Since 2020, Gloucestershire Hospitals NHS Foundation Trust has paid over £20 million in birth injury claims. These are overwhelmingly cases that occurred under obstetric-led care — in the very environment being defended as “the safest place”.
If “safety” were really the guiding principle, we would expect the service with the highest rate of catastrophic harm — and the highest financial liability — to be the one under restriction, review or temporary suspension.
But that isn’t what’s happening. Instead, the safest parts of the system (home birth, midwife-led units, continuity-based community care) are being dismantled, while the part of the system generating the most severe injuries remains unquestioned, protected, and described as the only “safe” option. This isn’t evidence-based thinking. It’s fear-based thinking. What women need is the right level of care, chosen with their midwife or obstetrician, based on actual risk — not assumptions, headlines, or paternalistic narratives about safety.
Evidence from comparable high-income health systems shows that better maternity care is achievable, affordable, and already in place in countries such as the Netherlands, New Zealand, Ireland and Norway.
These systems achieve safer outcomes for women and babies than the UK on key indicators, including maternal mortality and neonatal or infant mortality, and tend to share a few common features: strong continuity of care, default midwifery-led services, clear escalation pathways for complications, and well-integrated hospital and community care. OECD country comparisons also suggest that these systems sit within broader health systems that are well resourced and organized around prevention, early identification of risk, and timely referral.
It is important to recognize that they are not “low intervention at all costs,” but systems that aim to match the right level of care to the woman’s actual risk, while maintaining rapid access to obstetric, neonatal and emergency support when needed.
The clearest comparable figures available in the sources are OECD maternal and infant mortality indicators, plus UK-specific MBRRACE data. OECD reporting says Norway and Ireland are among the countries with maternal mortality ratios below 3 deaths per 100,000 live births, while the OECD average was 10.3 in 2023; the UK’s maternal mortality rate from MBRRACE reporting for 2022–2024 was 12.8 deaths per 100,000.
Our ask:
If you are on HOSC, if you work within NHS Gloucestershire, or represent this county:
Before you make another decision about maternity services, look at the evidence.
Not the optics, not the fear, not the defensive instinct to medicalize everything.
Look at the data, look at the international comparisons, look at the CTG evidence, look at the homebirth data, look at the maternal request research, look at what actually keeps women safe.
Then look at the Law and Legislation.