Since 1960, the Association for Improvements in the Maternity Services (AIMS) has campaigned to improve the UK's maternity services. The charity also supports women and birthing people, as well as their families and carers directly through a helpline and by sharing information in their books, journal and website.
AIMS is a volunteer-run charity, consisting mainly of lay people, although it does include midwives and other medical professionals. The charity's vision is ‘a future where every family has a positive maternity experience where they feel informed, heard and respected’. Its mission is to ‘support all maternity service users to navigate the system as it exists, and campaign for a system that truly meets the needs of all’. This is supported by three pillars of work:
- Providing objective, accessible, evidence-based information tailored to the needs of maternity service users and those who support them
- Providing individual support and tools for self-advocacy
- Campaigning and lobbying at a national level for service improvements that the charity believes are needed.
As a campaigning organisation, the aim is to engage in the national debate as an effective and well-informed lay voice, and act as a ‘critical friend’ for the development of initiatives and guidelines. The charity's key long-term campaigns are for:
- Physiology-informed maternity services
- The sustainable implementation of continuity of carer
- The implementation of better births in England
- Equity in maternity services. Examining the first of these campaigns,
AIMS would like to challenge readers to take a deeper look at ‘routine’ practices and consider what helps and what harms physiology. Perhaps there will be more questions than answers, and readers will be inspired to heed our call to action.
AIMS is campaigning for maternity services to develop a ‘physiology-informed’ approach to care and service provision. This approach both maximises the chances of pregnancy, labour, birth and the postnatal period remaining problem-free, without any requirement for medical treatment, and supports the delivery of timely, safe and effective medical treatment when this is beneficial and wanted. It underpins a holistic approach to maternity safety, promoting wellbeing and avoiding causing harm to the short- and long-term mental and physical health of the whole family, as well as reducing the risk of mortality and short-term physical harm.
Definitions of ‘normal’ labour and birth usually centre around spontaneous onset and progress of labour, and a vaginal cephalic birth without medical intervention (Werkmeister et al, 2008). It has been estimated that only about 28.7% of UK births are ‘normal’ in this sense (Prosser et al, 2018). Thus ‘normal’ birth is statistically abnormal. Since the Kirkup (2015) report of 2015 and more recent Ockenden (2022) report, there has been a tendency to equate promoting ‘normal’ birth with organisational pressures to achieve a low caesarean birth rate. ‘Normal’ is often equated with ‘vaginal’, even if interventions have occurred.
The AIMS campaign is very far from promoting ‘normal’/vaginal birth ‘at any cost’, but a deep understanding of physiological processes can benefit birth however and wherever it takes place.
Obstetric intervention is increasingly common, although ‘most women want a physiological labour and birth’ (World Health Organization, 2018). The AIMS helpline volunteers regularly hear from people planning a homebirth or freebirth, or those who are turning to doulas, because they believe that they will not get this in an NHS hospital. AIMS does not promote any particular type of birth, but does believe that maternity services that are designed and act with an understanding of physiology will maximise the chances of a spontaneous vaginal birth, if that is what the individual wishes.
No intervention is entirely benign, and giving truly informed consent requires personalised, accurate and evidence-based information to be shared and understood. AIMS proposes that discussions around care should start from the basis of doing nothing, and likely outcomes in that case, versus the benefits and risks, including the potential impact on physiology, of each proposed intervention.
The Birthplace study (Hollowell et al, 2011) demonstrated that in low-risk pregnancies, planning to give birth in a hospital was associated with increased interventions and adverse outcomes. The reasons for this are unclear, but it may be that out-of-hospital settings were better at supporting physiology. The emotional and relational aspect of midwifery-led models of care are well-understood, yet organisational practices do not always support this. AIMS asks what if care in both obstetric and midwife-led units placed emphasis on pregnancy and birth as a transformative process (Dixon et al, 2013), valuing and prioritising the relationships and emotional wellbeing?
Despite drives towards evidence-based practice, much of modern practice is without evidence and influenced by defensiveness. It is only ethical that services are honest about recommendations that lack sound evidence. Continuous electronic fetal monitoring in labour is often recommended for ‘high-risk’ pregnancies, but the evidence is severely lacking (Small et al, 2020). Conversely, it is well established that mobility in labour is associated with a higher chance of spontaneous birth (Prosser et al, 2018). A physiology-informed service could start by making simple changes to the environment of birthing rooms on a consultant-led unit to promote this.
Immediate cord clamping was once part of ‘active management’. While waiting for at least a minute is now the accepted norm (National Institute for Health and Care Excellence, 2015), healthcare professionals could also consider the physiological approach known as ‘wait for white’ (Tommy's, 2021). A physiological approach could also be extended to less well-understood areas, such as neuroendocrine mechanisms and microbiomes.
AIMS remains optimistic that with a renewed focus on understanding physiology, staff can be supported to champion with confidence a salutogenic approach, facilitating the normal physiological processes of pregnancy, labour, birth and the postnatal period where all is well, and spotting where there is pathophysiology so that interventions can be offered to maintain safety and focus scarce resources where they are needed.
The charity needs the help of health professionals to develop the vision of a fully physiology-informed maternity service, with a checklist of actions needed to achieve this vision and a set of action-inspiring short case studies of how an understanding of physiology has improved maternity services