In May, charity representatives, campaigners and MPs gathered in parliament to hear the then Conservative MP Theo Clarke launch the UK’s first national birth trauma inquiry. More than 1,300 people had submitted evidence, including parents who had lost babies and women with lifelong injuries and post-traumatic stress disorder.
Also there that evening was Angela McConville, the chief executive of the National Childbirth Trust (NCT), a parenting charity best known for the antenatal groups it runs for expecting parents. “Genuine sadness and emotion in parliament tonight,” McConville wrote in a post on X.
Fiona Winser-Ramm of the Maternity Safety Alliance, a group of bereaved families campaigning for a public inquiry into maternity services, saw the tweet that night and says she “felt like screaming” with rage. In 2019, Winser-Ramm, a teacher and safeguarding officer, attended NCT classes while pregnant with her first child, Aliona. Aliona died on New Year’s Day 2020 due to neglectful care at her birth. Staff at Leeds General Infirmary didn’t act when there was meconium (a baby’s first faeces) in Winser-Ramm’s waters, nor when Aliona’s foetal monitor showed she was in distress, nor when Winser-Ramm and her husband repeatedly expressed concerns about how her labour was progressing.
Winser-Ramm, who is 38 and lives in Leeds, believes the NCT should have taught her information that could have saved her daughter’s life – such as the fact that she should have been informed of her daughter’s foetal monitor readings regularly. The NCT taught her, Winser-Ramm says, that “we don’t need to talk about these things [birth trauma and baby loss], because they don’t happen very often and most of the time it’s fine”.
When she saw McConville posting a selfie at the launch of the inquiry, she felt cold fury. “Watching them stand around, I felt like shouting: ‘You are the problem! You are contributing to this.’”
The NCT is the largest provider of antenatal education in the UK, running a mixture of private courses, which cost up to £299, and free-to-access classes on behalf of NHS trusts. According to the NCT, more than 75,000 people a year attend its classes to learn about childbirth and the post-birth period, as well as to make friends with other expecting parents in their area.
“It’s lovely to know other mums hitting the same hurdles as you, so you don’t feel alone,” says Sinead Knights, 38, a travel industry manager from Manchester who did NCT classes in October 2023. She describes them as “a space to share ideas and ask questions and not feel judged” and says she meets up with the mothers from her group weekly. “Hopefully, our babies will be friends for a long time, as the mums will as well,” Knights says.
For many parents, the support and camaraderie they found through the NCT is invaluable. But according to its critics, the NCT’s focus on natural birth – inherent in its original name, the Natural Childbirth Association – has contributed to real-world harm for parents and babies. When ideology enters healthcare, things can – and do – go wrong. Over the past decade, three independent, government-commissioned reports have identified natural birth philosophy, including a reluctance to perform caesareans, as a contributing factor in maternity scandals. So how did the NCT’s founding values come to have such an influence on UK maternity services?
The NCT was established in 1956 by Prunella Briance, inspired by the teachings of the British obstetrician Grantly Dick-Read. Childbirth, said Dick-Read, is not inherently painful. It hurt when women – usually educated women in western countries – felt fear, through what he called the “fear‑tension-pain syndrome”. If women relaxed and stopped worrying about childbirth, they could have painless, unmedicated births. Dick-Read became the NCT’s first president and his teachings were enthusiastically promoted by middle-class women, who met at antenatal groups in each other’s homes.
It is easy to see why these messages about natural birth became popular. Who wouldn’t want a painless, straightforward, unmedicated birth? In the 1950s, most women gave birth in hospital, where they were subjected to dehumanising treatment by doctors. They were shaved and given enemas; the unmerited use of forceps and episiotomies – cutting the perineum to widen the opening of the vagina – were routine. Many of the pioneers of the NCT endured traumatic hospital births. Briance’s first daughter was stillborn. The prolific writer and NCT tutor Sheila Kitzinger’s doctor gave her a “husband stitch”, an unnecessary suture to reduce the size of the opening to her vagina for the benefit of future sexual partners.
Over the coming decades, natural-birth activists rebranded childbirth from a degrading medical procedure to a life-affirming experience. Outcomes such as prolapses, haemorrhages and death often weren’t discussed, lest women become frightened and activate the fear-tension-pain syndrome.
At its earliest inception, an anti-medical agenda underpinned the NCT’s philosophy of birth. “As childbirth is not a disease it should take place in the home wherever possible,” read its founding statement. “If impossible the maternity units should be homely and unfrightening and in no way connected with ‘hospital’.” Reclaiming birth from male doctors – who would try to force medical interventions such as inductions, epidurals, forceps and C-sections on women – was seen as a feminist act.
Even by 2002, the NCT’s stance had not changed much from its original aims. “We would argue that the medical model of care, in which the perspective of doctors dominates the way services are run and developed, is a key contributory cause [to the rising caesarean rate],” read an NCT response to the health select committee. “The medical model of care concentrates on looking for pathology and intervening to treat pathology when it occurs. The model fails to understand that birth is a physiological process which needs to be protected and promoted.”
The NCT helped to popularise the term “cascade of intervention”: the idea that one intervention during birth, such as an induction or an epidural, begets another. In her 2013 book Do Birth, Caroline Flint, a former NCT teacher and trustee, provided women with a script to help them “negotiate” with doctors if they recommended unwanted medical interventions. “Many doctors find it almost impossible not to intervene unnecessarily,” Flint wrote. “They must always be doing something to help things along. When midwives are experienced and strong, they keep doctors away from women in normal labour … The tragedy of modern times is that doctors don’t see that their presence is an intervention in itself.”
One retired NHS obstetrician I speak to recalls getting a Christmas card from the NCT. It showed a male doctor scowling at a pregnant woman. “A normal birth?” he said. “You’re making life very difficult for us.” Behind his back, he held a folder titled “Caesarean”.
When contacted for comment, Flint said that she had “deep gratitude” for doctors and that modern medicine had saved her life on more than one occasion. However, regarding childbirth, she said she believes that the “modern invasive and pro-active approach” is “not appropriate”: “A woman who is infused with oxytocin during a normal labour is more ready to fall in love with her baby – this is really important. The love of a mother for her baby ensures the safety of that baby.”
The NCT has always been a campaign group. The fact that partners can support women during labour and that breastfeeding is legally protected is largely down to the work of its members. But the NCT has also lobbied for policies that now appear at best ill-judged, and at worst, dangerous.
In 1999, the NCT set up the Maternity Care Working Party (MCWP), a group that included members of the Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG). One of the MCWP’s objectives was to reduce the rate of C-sections being performed in hospitals, which had “reached unacceptable levels”, according to the NCT’s then chief executive, Belinda Phipps. The NCT was not alone in raising this as a concern. The World Health Organization says there “is no evidence showing the benefits of caesarean delivery for women or infants who do not require the procedure” and that, since 1985, “the international healthcare community” has considered the ideal rate to be between 10% and 15%.
In the 12 years to July 2003, the C-section rate in the UK doubled. In 2000, the health department commissioned an audit of all births to determine why the rate had increased and found that one in five births in the UK were performed by caesarean. Compared with vaginal births, C-sections cost the NHS more, have a longer recovery time and higher maternal mortality rates, and carry risks of infection. For babies, they have been linked to increased rates, albeit very small, of obesity and asthma.
But despite these risks, a C-section is often the only way to deliver a baby safely. Had Winser-Ramm been given a caesarean earlier in her labour, her daughter would have survived. “These interventions can mean the difference between your baby being born alive and dead,” she says.
The NCT argued that most women preferred to have vaginal births, but were often denied the choice – and that, overall, “normal” births were much cheaper for the NHS. It argued that women should be supported to have home births or give birth in midwife-led units, where they were more likely to have a positive birth experience. It also argued that doctors were performing C-sections unnecessarily. By the early 2000s, the NCT had jettisoned the term “natural birth” in favour of “normal birth”, meaning a vaginal birth without interventions such as epidurals and C-sections.
If these “normal” births were painful, what of it? As Phipps told the Telegraph in 2008: “If we just dropped babies like eggs without noticing, what would that say about the responsibilities we’re taking on for the next 20 years? Birth marks you out as a mother and a carer for a very long time.”
Today, Phipps says: “It’s devastating to see the NHS has learned almost nothing and is still failing to provide women with a service which enables them to have a safe and empowering birth. Women want to be listened to and be taken seriously.”
Kim Thomas, the CEO of the Birth Trauma Association, freelanced for the NCT from 2009 to 2014. “We were always talking about the importance of evidence,” she says. “And yet there was this very clear ideological position in favour of normal birth and reducing the number of C-sections.” Her former colleagues, she says, were well-intentioned people, who sincerely wanted to make birth better for women. “They thought that promoting normality was the way to do it,” she says.
An academic who worked with the NCT in the 2000s, but prefers not to speak publicly, says that the NCT “did not have the power to change government policy themselves. There was a widespread recognition at the time that maternity services needed to be more women-centred. Their input was a response to hearing women’s stories of unconsented treatment and lack of autonomy.”
Over the 2000s, the NCT, through the MCWP, formed alliances with parliamentarians. In 2007, the NCT secured its greatest achievement, drafting a Normal Birth Consensus Statement with the RCM and the RCOG. The statement called for NHS trusts to promote and support normal birth, reduce interventions and publish statistics on how many women were having C-sections.
In 2010, the National Institute for Health and Care Excellence (Nice) published a toolkit, welcomed by the NCT in a foreword to the report, urging hospitals to aim for a C-section rate below 20% and ideally below 15%. Two years later, the NCT helped draft guidance for NHS clinical commissioning groups in England, in partnership with the royal colleges, that pressed them to aim for a C-section rate of 20%.
More than a decade of concerted lobbying had come to fruition. Normal birth was now official NHS policy.
In 2012, the same year that English hospitals were urged to aim for a C-section rate of no more than 20%, a pregnant woman was admitted to Shrewsbury and Telford hospital. She didn’t want a vaginal birth. She had already had one C-section and told staff she wanted another. But they persuaded her to have a vaginal birth. About one in 200 women who have a vaginal birth after one C-section will suffer a uterine rupture, which is when the uterus tears apart. It can be fatal for mothers and babies. The mother was given an oxytocin drip, also known to increase the risk of uterine rupture, and doctors failed to notice that her baby was stuck. The mother had a uterine rupture and her baby died. Shrewsbury and Telford NHS trust never apologised or identified any failings in her care.
A decade later, Donna Ockenden, a midwife, published her landmark report on maternity failings at the trust. The report found that 12 mothers and at least 124 babies died after receiving poor care.
Throughout the 2000s and the 2010s, Shrewsbury and Telford NHS trust was seen as a poster child for exemplary maternity care. Its C-section rate was just 16.3% in 2013-14, compared with an average in England’s NHS hospitals of 26.2%. The trust was extremely proud of its low C-section rate. “We have to do everything to get a vaginal delivery and we’ve got to keep the section rate low,” one member of staff told Ockenden’s investigators.
Ockenden found that women were talked into having vaginal births despite the fact that they had babies in breech position, they had previously had C-sections or their babies were in distress. C-sections were delayed unnecessarily, sometimes leading to the death of babies. Shortly before Ockenden’s report was published, NHS England told hospitals to stop pursuing normal births and that C-section targets were potentially unsafe.
Ockenden’s findings were not unique. In all three of the independent reports into the avoidable deaths of mothers and babies in English NHS maternity units over the past few years, a reluctance to perform caesareans and a push for natural births is identified as a contributing factor. In his 2015 report on failings at Morecambe Bay NHS trust, Bill Kirkup found that midwives pursuing “normal childbirth ‘at any cost’” had contributed to the deaths of three women and 16 babies shortly after birth. Kirkup’s 2022 report on what he described as the “deplorable and harrowing” deaths of dozens of babies at East Kent hospitals university NHS trust’s maternity services also found that normal birth was the “ideal that staff and women should strive to achieve”.
The NCT released statements in response to each of these reports. None of them make reference to the C-section targets it pushed for in the consensus statement or to the promotion of normal birth. The organisation did point to staffing and investment issues within NHS maternity services. An NCT response to Ockenden’s report read: “The report is clear in its recommendations. We wholeheartedly support the call for major investment to ensure a safe, skilled maternity workforce who feel valued and supported in their roles.” The RCM and the RCOG, who signed up to the normal birth consensus statement, have each apologised for their role in promoting normal births.
Four days before the publication of Ockenden’s report, however, the i paper found that the NCT had deleted some of the content on its website promoting normal birth. “Try to avoid stimulating the rational part of your brain [in labour],” read one deleted post. In another post that was taken down, the organisation advised women that a vaginal birth after four previous C-sections was as safe as a planned C-section. In reality, says Kenga Sivarajah, a senior obstetrician at King’s College hospital in south London, the risk of uterine rupture is so high that we don’t even have figures for it.
“My biggest issue with the NCT and other organisations in this space is that they have never taken real responsibility for their role in what happened to some mothers and babies,” says Pauline McDonagh Hull, who advocates for better access to elective C-sections.
According to the academic who worked closely with the NCT in the 2000s, “the NCT was working with others in good faith to improve wellbeing for mothers and babies. If there is a lesson, I guess it would be: ‘Consider longer-term unintended consequences of the changes you seek.’”
When contacted for comment, the NCT’s McConville said she wanted to start “by acknowledging the bereaved and traumatised parents at the centre of this story, who deserve immense compassion and empathy. Every parent has a fundamental right to a safe and supported birth.” She added that “some of NCT’s historical policy positions do not align with the needs of new parents today and do not reflect the current context in which parents are giving birth. We believe there is no such thing as a normal birth and today our charity’s vision, mission and strategy strongly reflects that.”
The NCT says its courses are evidence-based and do not favour normal over medicalised births, adding that its course materials were refreshed in 2019 to cover all the ways women can give birth, without promoting one way or another.
“Our mission is to support everyone who becomes a parent, regardless of their circumstances or the birth and feeding decisions they make,” says McConville. However, this message does not appear to have filtered through to all NCT trainers on the ground.
One NCT tutor recently shared a post advising women to lie to their doctors about their due date, implying that women shouldn’t listen to male doctors amid what she described as an “epidemic of induction” because “no uterus, no opinion”. Last month, a senior NCT policy adviser, Elizabeth Duff, was forced to apologise after a post on X that read: “Some women – not all – think of their about-to-be born baby in the same way as they will soon do of their newborn. And would consider carefully about giving powerful analgesics [painkillers] to their new baby, when perhaps cuddling, rocking, soothing strategies might help too.”
Conversations with multiple recent NCT attenders who responded to a Guardian callout reveal that natural birth is still foregrounded in classes, even after the 2019 changes.
Chelsea Fawcett, 32, a nurse from York, attended an NCT course during her pregnancy in 2023. She remembers her tutor saying that if she had an epidural, she was more likely to have a C-section. “She kept saying: ‘What we tell you is evidence-based.” (Epidurals do not increase the likelihood of having a C-section.) Fawcett had planned for an epidural, but, after attending the classes, “all these things I was open to before I was suddenly terrified of”, she says.
Her labour was excruciating, but Fawcett refused an epidural. “I was so scared of the ‘cascade of interventions’,” she says. “I thought it was better to push through the pain. Next time, I am definitely having an epidural.”
Sivarajah has encountered women in extreme distress who were rejecting epidurals due to misinformation about their risks. When she questioned where this misinformation came from, “I started to realise: they’ve been told this in their antenatal classes.”
Sivarajah had a positive experience attending NCT when she was pregnant. However, she wonders if the public understands “that NCT is run by non-medical professionals”. NCT tutors take a one-year course. There is no requirement for them to have medical or midwifery qualifications. “As an obstetrician, I’ve trained since I was 18,” says Sivarajah. “I’m 41. It’s taken me a long time to understand why some women are high-risk, why some women are low-risk.
“Doctors don’t intervene because we want to medicalise birth. I don’t go into a labour ward thinking: ‘I want to do a C-section on every woman here.’ But, unfortunately, there are some scenarios where that is the only way we can safely deliver a baby.”
Thomas says she often encounters women who “feel like failures if they haven’t had a ‘normal’ birth”. The historian Hilary Marland, who analysed the NCT’s campaign work from its formation in 1956 to the 1980s, found that its “model of idealised natural birth [may] have contributed to, rather than reduced, mothers’ mental distress”.
Helena, 39, works in change management and lives in south London. She started NCT classes in July 2021. Her trainer emailed the group, stating that men did not need to attend the session on pregnancy complications. (The trainer later said men could attend; some men were at the session.) “Surely that is the one where you really need your partner to know what is going on?” Helena says.
Many feel the problem is that NCT tutors are subject to very little oversight. “Historically, there’s been a lack of centralised quality control,” says Thomas. “Some NCT teachers did a good job. But others didn’t. And that’s where the problem lies.”
McConville says: “Over the last four years, we have been working to transform and modernise our charity to respond to this crisis in the UK’s maternity system, and to equip parents with comprehensive, accurate and impartial education, content and services. Of course, there is still more for us to do.”
Despite recent changes, a subtle pro-normal-birth approach remains on the NCT website. The risks of vaginal birth are downplayed: it describes the risk of urinary and faecal incontinence after a vaginal birth as “very small”. According to an evidence review by Nice, up to 49% of women who plan vaginal births will have urinary incontinence and up to 15.1% will have faecal incontinence for at least a year after birth.
Obstetric medicine has made childbirth safer than ever, but you need only to look at the curving steel of a pair of forceps, and feel the weight of them, to realise that birth can still be medieval. “Risk in labour can change from minute to minute,” says Sivarajah.
The birth trauma inquiry recommended that all NHS trusts provide antenatal classes. “We should treat women as adults,” says Clarke, who led the inquiry. “And we should allow them to make up their own minds. And we should give them the information so they can make an informed choice during childbirth.”
The former Conservative MP attended NCT classes when she was pregnant in 2022. “I was quite disappointed with the course content,” she says. “I feel there was very much a focus on natural birth. I was told: ‘We’ll be having a water birth, they’ll be following your birth plan.’ When I did try to raise risks in the group classes, they were dismissed and I was told we didn’t need to discuss that, because the likelihood was very low.” Clarke had a traumatic birth. “Given the NCT is the largest provider in the UK for antenatal education, they need to do a better job of informing women,” she says.
Clarke would like the NHS to run antenatal courses. But after the launch of the birth trauma report, the NCT put out a response that ended with it pitching to provide these classes. It already runs antenatal classes on behalf of five NHS trusts.
“We obviously don’t want to scare mothers who are about to give birth,” says Clarke. “At the same time, we must allow adults to have an informed choice. And I do not believe that’s currently the case in the UK.”
The NCT is not the only provider of information for pregnant women. The RCOG’s president, Ranee Thakar, admitted to the birth trauma inquiry that doctors don’t give women full information, “because we think that women will be frightened and they will want to have a caesarean section if we tell them about birth trauma”.
But we are at a turning point. The website birthfacts.org was compiled by an independent researcher after their partner had a traumatic birth injury. All of the information comes from official statistics or systematic reviews, meta-analyses and large, peer-reviewed studies. The author of the website, who is anonymous to protect their partner’s privacy, hopes that it will be a principal source of information for women.
At the University of Cambridge’s Winton Centre, researchers are working on a decision-making tool that will provide pregnant women with facts about different modes of childbirth, to be given out by NHS trusts. “Particularly within maternity, there has been a lot of paternalistic behaviour and not wanting to give people the full information,” says Alexandra Freeman, one of the tool’s authors. “We want to inform and not persuade, to give people information so that they can apply their own values to it, not to give them information that has already been filtered through a values set.” Freeman is horrified by the term “the cascade of interventions”: “We would never use that kind of language.”
The decision-making aid uses numbers wherever possible. “Language is really subtle,” Freeman says. “People slip in words like ‘fewer’, ‘only’, ‘less’, ‘more’. If you are saying ‘less’, how much less? We try to give numbers. We’d never say ‘only’. That turns a number into a persuasive form.”
What all this comes down to is information. What are antenatal classes for? Are they to educate or to persuade? Is something “evidence-based” if the evidence has been selected to reinforce a worldview? Should women be trusted with the fullest science available – acknowledging, of course, that science is never final? Will the truth frighten them or empower them to make better decisions?
“It’s awful to make a decision and find out you were basing it not on the full information and regretting that decision all your life,” says Freeman. “If you make a decision based on all the information and it doesn’t turn out well for you, it’s very different.”
