Old, Fat Women & Midwife Ideology are to blame…

By Alex Burner

So recently the press has made a lot of noise about this idea that midwives are pushing natural birth above all else and this is the reason we have a problem with maternity outcomes in the UK. Doulas get thrown into the mix too … we have a financial incentive to push our agenda of “natural birth” (and whilst that’s probably a discussion for another day. Let me state it clearly here… doulas are not incentivised to push any kind of birth agenda - natural or otherwise. A doula’s role is to help advocate for the decisions made by their clients for themselves about their birth and their baby. Doula support - emotional, physical and advocacy - is well documented in improving birth satisfaction and positive outcomes for parents and their babies.https://evidencebasedbirth.com/the-evidence-for-doulas/)

Apparently this obsession with “natural birth” combined with the fact that we’re all getting too old and too fat to give birth without assistance means that women and birthing people, and midwives, have created this perfect storm in maternity services in the UK. A storm whereby we are seeing lots of medical intervention at births and not enough well trained, experienced staff to support all these “old fat women” who need help to birth their babies. All whilst doulas look on in the background, chanting, and blowing incense up the birthing persons vulva, whilst whispering in their ears about the glory of freebirth.

However, if we take a step back and look at how we got here some interesting points come to light. I am neither an investigative reporter nor a social scientist but several questions keep coming to mind. Are we really all too old, and fat to give birth? And are midwives actually pushing this agenda of “natural birth” above all else or has something got lost in translation? If social scientists and investigative journalists were actually to step foot into the maternity space (and not simply talk to a handful of incredibly traumatised families after the fact) they might see something very different. 

Midwives and doulas are in the birth space on a daily basis. What midwives are reporting is a complexity of cases, women and birthing people demanding care outside of guidance. What doulas are seeing is women and birthing people who are coerced and scared, not receiving adequate care and support from medical professionals who are meant to be working in their best interest. 

Whilst women and birthing people may have become more demanding of their right to things like a home birth or to not have non-evidence based interventions in their births - CTG monitoring, vaginal examinations etc. Are they really all older and fatter and unhealthier, and is this the root cause of the problems in NHS maternity care? It doesn’t take a lot of digging in the Office for National Statistics to firstly belay the myth that we’re suddenly all too old and fat to give birth. 

Obesity is rising amongst women and birthing people of reproductive age. From 16% in 2000 to 26% in 2025. A 10% increase is a relatively significant number. Whilst we know that higher BMI is associated with several pregnancy related conditions, there is plenty of research to counter the idea that obesity alone should be a significant predictor of your birth outcomes. 

Looking at one of the main associated concerns relating to obesity in women of reproductive age - hypertension - the second leading cause of induction in the UK (hypertension and pre-eclampsia) - only 1 in 10 are diagnosed with hypertensive disorders whilst pregnant. Yet note … hypertensive disorders are the second leading cause of induction. More on this is a moment. Maternal age. Often discussed, too many women and birthing people are leaving it “too long” before having their first baby these days, while politicians wring their hands over the falling birth rate. Whilst thankfully we have expunged the practice of marrying off girls in their early teens and expecting them to successfully reproduce here in the UK, the age of women and birthing people giving birth to their first child has only risen 2 years in the last 25 years. From 27 in 2000 to 29 in 2025. Whilst this is projected to continue rising, for now we’re not actually that much older when we have our first babies than we were two decades ago!

But, what has risen incredibly drastically is the induction and Caesarean section rate.

There is absolutely no judgement here about having a Caesarean. As a doula, and a feminist, and a woman, I believe we absolutely have the right to choose how we give birth. What I have an issue with is the number of seemingly unnecessary or unwanted Cesarean sections that are taking place. These numbers are significant, with a national average of 42.4% in 2024, given that we're blaming midwives for pushing the agenda of “natural birth” and we’re blaming women for their inadequate bodies. 

The induction rate in the UK has risen by a staggering 21.5% in the last 25 years.

The leading reason given for induction in the UK - “prolonged pregnancy”, i.e. you've gone beyond 40 weeks gestation. It’s important to note that this statistic doesn’t include cervical sweeps (which is a non-evidence based intervention designed to end a pregnancy before the baby is ready to be born). It isn’t counted in maternity statistics as part of the induction process. We also know that this number is a conservative average with some Trusts in the UK documenting inductions rates of around 50% regularly month on month. 

So if women aren’t being induced because they’re too fat (hypertension and pre-eclampsia, often associated with higher BMI in pregnancy are only the second leading reason for inductions), then why are so many women and birthing people being induced when statics shows little improvement in outcomes for babies or mothers over those who choose to wait until their babies instigate the start of labour. Something which absolutely does not reconcile with midwives supposed “obsession” with “natural birth”. If midwives were truly obsessed with “natural birth” they would be strong-arming everyone into waiting for labour to start naturally, when the baby is ready. But they’re not. In fact induction is offered to many women and birthing people around 39 weeks at antenatal appointments, where they’re told “We’ll just book you in for your induction now, just in case”. This is commonly known in midwifery as defensive practice. 

The UK Caesarean rate is currently, as of 2024, 42%. This is alarming when the WHO recommends a healthy Caesarean section rate should rest around 15%. The evidence is clear that this Caesarean rate is not a result of women who are demonised as “too posh to push”, or too lazy to give birth. Many of these inductions are pushed on women and birthing people for “safety”, and because other previous interventions have gone badly wrong causing distress to the baby, or potential harm to the mother. It’s evidence base that if you have an induction that you’re more likely to have a Caesarean section. In recent research a whopping 35.9% induced went on to have caesarean vs non-induced at 18.9%. https://pmc.ncbi.nlm.nih.gov/articles/PMC6366839/

Dr Sara Wickam does a deep dive into the impact of induction on Caesarean rates. https://www.sarawickham.com/research-updates/induction-increases-caesarean/ 

At the same time as these things are occurring other interesting variables are coming into play. The NHS is chronically underfunded, maternity and mental health services suffering disproportionately. According to figures posted by the Royal College of Midwives we have a 2500 deficit of midwives. You don’t have to look far on social media to see midwives reporting leaving the service in their droves due to horrific working conditions, bullying and stress. This is combined with the fact that midwives are struggling to get jobs in the first place despite the dire need. The RCM recently wrote a press release stating that midwives are completing their degrees and struggling to secure work because Trusts can’t afford to hire. 

We’re seeing a high number of midwives leaving the service, a huge proportion postponed retirement during and in the immediate aftermath of COVID, and they’re now leaving. These midwives aren’t being replaced with similarly skilled midwives as they simply aren’t available. Which means we’re seeing situations where inexperienced midwives who aren’t well supported at work are being forced to care for seemingly “more complex” cases that have been created by a system that is pathologising pregnancy and birth to the extent that to sail through your pregnancy and birth without being considered “high risk” or “more complex” is virtually impossible. 

So understaffed maternity wards are being put under increasing pressure from the number of people being booked for inductions and Caesarean sections. ⅔ of home birth services in the UK are either suspended or restricted. This compounds the deskilling of midwives, meaning they simply don’t feel safe and competent in their work. This has been highlighted by the tragic case of Jen Cahill, who passed away with her daughter after a home birth went tragically wrong. The coroner's report highlighted the fact that the midwives weren’t experienced in home births and didn’t have all the information they needed to adequately take care of her. It highlighted the fact that Community Midwives were often only attending a handful of births a year because there is no requirement, once qualified, for how many births midwives should attend. 

Where does this leave us? In a strange game of “who should we blame this week”. All of which detracts from the fact that the national investigation into maternity services has been delayed in its reporting, women and birthing people still aren’t being listened to and constantly blamed for their bodies being inadequate at birthing their babies, midwives aren’t being suitably trained, supported and recompensed for their incredibly challenging work. 

The system that is the NHS continues to push the medicalisation of birth in an effort to systematize and streamline, and save money, all at the expense of those who work within it and are cared for by it. And were you to think the system was designed this way and is performing perfectly well or you think the system is failing and no amount of sticking plasters will fix it, what is clear is that those who continue to suffer are those who have little in the way of actual, real choice about using the system or going it alone. Neither of which is particularly attractive to mothers who simply want to birth their babies in the safest, and most supported and cared for way possible.