Continuity of midwifery care is an ecological model of healthcare

I've been thinking more and more about the distressing, heartbreaking and avoidable tragedies for mothers, babies, their families and their communities in the various reports from the UK.  I've also been thinking about the fixation on 'normal birth ideology' and the idea that individuals are to blame for the horrific morbidity and mortality exposed in these reports, rather than highlighting how the system needs to change. I've lamented that the 'system is broken', but I'm realising that saying the system is "broken" implies that it has failed to do what it was intended to do. Many of the characteristics we now criticise in maternity care: fragmentation, hierarchy, surveillance, standardisation, control and efficiency, are not accidental. They arise from a worldview that has historically privileged control over relationship, production over care, and certainty over complexity. The maternity care system reflects patriarchal values and assumptions that have shaped institutions over centuries.

 What if maternity care reflects our relationship with the living world?

I am proposing another idea. Perhaps the maternity scandals are not only telling us something about healthcare. Perhaps they are revealing something much deeper about our culture. Across the world, we have inherited systems built upon a particular way of seeing the world. A worldview that values certainty over uncertainty, control over relationship, measurement over meaning, and production over care. It is a worldview that has delivered extraordinary scientific and technological advances, but it has also encouraged us to see living systems as something to be managed rather than understood and valued.

The natural world has long been treated this way. Rivers have been straightened. Hills levelled. Forests cleared. Wetlands drained. Predators eliminated. Landscapes divided into parcels that can be measured, controlled and exploited. Complexity is often viewed as a problem to be simplified, rather than a source of resilience. Wildness is regarded with suspicion because it cannot always be predicted.

Women's bodies have frequently been approached in remarkably similar ways.

Pregnancy becomes a condition to monitor. Labour becomes a process to manage. Birth becomes a production line with predefined timelines, protocols and performance indicators. The extraordinary intelligence of physiology, the intricate orchestration of hormones, emotions, relationships and environment, is often reduced to a series of variables to control.

Yet physiology is not a machine. It is an ecosystem.

Like every ecosystem, it responds continuously to its surroundings. A forest cannot be understood by measuring a single tree. A coral reef cannot be understood by studying one fish. Likewise, birth cannot be understood simply by monitoring cervical dilatation, contraction frequency or fetal heart rate. These are important, but they are only fragments of a much larger living system. Birth unfolds within an ecological network of hormones, relationships, emotions, history, culture and environment that interact continuously with one another. Modern science is increasingly confirming what experienced midwives have always observed: physiology is exquisitely sensitive to context. Oxytocin is influenced by safety. Stress hormones respond to fear. Labour can accelerate when a woman feels protected, or slow when she feels observed, threatened or alone.

The environment is not merely the backdrop to birth. 

The environment becomes part of the physiology itself. This is why relationships matter so profoundly. A trusted midwife is not simply another member of the workforce. She becomes part of the woman's physiological environment. Her calm presence can reduce fear. Her familiarity allows subtle changes to be recognised early. Her relationship creates the conditions in which women feel safe enough to labour, ask questions, express uncertainty, and trust their own bodies.

Continuity of midwifery care is therefore much more than a model of service delivery.

It is the deliberate creation of the ecological conditions in which physiology is most likely to flourish. This way of thinking also helps explain why so many dedicated midwives find themselves working in ways that do not reflect their own values.

People adapt to the systems they inhabit.

When success is measured primarily through efficiency, throughput and compliance, relationships inevitably become secondary. Time spent listening appears unproductive. Knowing a woman deeply becomes an unaffordable luxury rather than a cornerstone of safe care. Compassion is squeezed into the spaces left between competing demands. It is hardly surprising that many midwives experience moral distress. They entered maternity care to care for childbearing women, yet often find themselves working within structures that reward the management of processes more than the nurturing of relationships.

The same worldview that has contributed to ecological degradation also shapes the way many societies organise maternity care. Both assume that living systems perform best when they are tightly controlled. Yet ecology teaches the opposite. The healthiest ecosystems are not those subjected to the greatest control. They are those with the greatest diversity, adaptability, connection and resilience. Their strength lies in relationships. Human beings are no different. Birth is one of nature's most sophisticated biological processes. It evolved, not in brightly lit clinical environments governed by clocks and protocols, but within relationships, communities and environments that promoted safety, connection and trust. This is not an argument against medicine. Medicine is one of humanity's greatest achievements and has transformed the survival of women and babies when complications arise. The question is not whether medicine belongs in maternity care. It unquestionably does. 

The question is whether medicine should define the entire philosophy of maternity care. 

When intervention becomes the organising principle rather than the response to need, we risk treating every birth as though physiology is inherently suspect. Perhaps that is the deepest lesson emerging from the maternity inquiries. Not that physiology has failed. Not that women have failed. Not that clinicians have failed. But that we have created systems shaped by assumptions that privilege control over connection, hierarchy over partnership, and surveillance over trust. If we genuinely want different outcomes, we may need more than organisational reform. We may need a different story about birth itself. One that recognises birth not as a process to be controlled, but as a living ecological event requiring knowledge, humility, relationship and respect. Because how we treat birth ultimately reflects how we understand life. If we continue trying to dominate living systems, whether forests, rivers or women's bodies, we should not be surprised when those systems lose their resilience. But if we learn to work with them instead of against them, supporting rather than controlling, partnering rather than overpowering, we may discover that the future of maternity care is inseparable from the future of our relationship with the living world.

 Every woman needs a midwife.

Not simply because she may need clinical care. But because every living system thrives through relationship. And some women need doctors too. Not as controllers of physiology, but as valued partners when physiology asks for more than nature alone can provide. That is not a compromise between two philosophies. It is the wisdom of recognising that both nature and medicine are at their best when they work in relationship rather than in opposition. 

The recognition that continuity of midwifery care is an ecological model of healthcare and one where women and babies are safest is an idea that sits at the intersection of maternity care, systems thinking, ecofeminism, salutogenesis, physiology, and relational care, aligning contemporary complexity science and ecological thinking with the physiology of birth rather than treating continuity simply as a service model.

 

Maternity scandals commentary keeps blaming 'normal birth' ideology. The real problem is broken systems

Another damning report into a maternity unit, another round of the same argument. Last month, Donna Ockenden's review into Nottingham's maternity services found 520 families had suffered avoidable harm, including 162 deaths. It is the latest in a tragic line of UK inquiries stretching back to Bill Kirkup's 2015 report into Furness General Hospital, where 11 babies and one mother died avoidably—among them Joshua Titcombe, son of patient-safety campaigner James Titcombe. Writing in the BMJ, Titcombe argued that a "damaging ideology" that prizes natural, "normal" childbirth over safety continues to cause preventable harm, and that inquiry after inquiry reports the same symptoms without confronting the root cause. I responded in the same pages. I don't think he's wrong that ideology causes harm. But I don't think the ideology in question belongs to midwifery. 

Shifting the Battlefield 

I wrote a paper 20 years ago about the politics of Australian midwifery. Back then, the fight was over whether midwives should be allowed to practise autonomously at all. That fight is largely over. Midwives here can prescribe, order tests, and bill Medicare; every state and territory now has a senior midwife advising government. What hasn't changed nearly as much is what happens to the small number of women each year for whom something needs to go differently, and that's exactly where the harm in these UK inquiries keeps turning up. If you read what the inquiries say, rather than what popular commentary claims they say, they don't conclude that "midwives got it wrong" or "obstetricians got it wrong." Instead, they describe: 

• Wards operating without safe staffing thresholds. 
• Fragmented multidisciplinary teams that do not communicate. 
• Toxic workplace cultures where clinicians are too afraid of blame to say, "I think something's wrong here." 
• Critical warning signs missed because nobody has the time, continuity, or standing to notice them.  

Occasionally, a report finds a rigid determination to achieve a vaginal birth that overrides a woman's or baby's obvious need for medical escalation. Yet both failures share a root cause, a system that doesn't give the people inside it the room to notice change and respond to it. That is a textbook definition of organisational failure. It is not a verdict on a philosophy of birth. 

The Best-Evidenced Infrastructure We Aren't Using 

This distinction matters because arguing about "normal birth versus medical intervention" distracts from the one intervention the evidence says reliably works: continuity of midwifery care. This is a model in which the same midwife or small team cares for a woman throughout pregnancy, birth, and the postpartum weeks. It sounds like a nice-to-have, but the data proves it is safety infrastructure. Recent studies, including work covering disadvantaged and First Nations communities, link continuity of care to fewer premature births, fewer unnecessary interventions, and fewer babies needing intensive care (Kuipers et al 2026, Lundborg et al 2025; Forster et al 2026). It works for much the same reason a GP who has known you for years notices subtle health shifts that a stranger in an emergency department might miss. Someone who knows your baseline can detect changes earlier, allowing for intervention before they become a catastrophic emergency. Yet, most Australian women still don't get this care. Not because the evidence is thin, but because our funding models, rosters, and hospital structures were built around short, disconnected appointments rather than relationships. Rebuilding a public hospital system around relationships is genuinely hard organisational work. It is not an ideological debate.

Understanding Physiology is Not an Ideology 

Supporting normal physiological processes is fundamental biology. Every area of medicine seeks to preserve normal physiology whenever possible: 

• Cardiology supports normal cardiac function. 
• Endocrinology supports normal glucose regulation. 
• Neonatology supports normal transition after birth. 

Maternity care should be no different. Understanding physiology does not mean refusing intervention. It means recognising how the body functions normally, creating environments that support those processes, and intervening promptly when physiology is no longer sufficient. Unfortunately, this distinction has become deeply blurred in public debate. The phrase "normal birth ideology" has become a convenient shorthand that conflates two entirely different concepts: 

1. Supporting physiological childbirth based on biological science. 
2. Pursuing a vaginal birth despite emerging clinical evidence that intervention is required. 

They are not the same thing. Indeed, one of the defining skills of expert midwives and obstetricians is recognising when physiology is progressing normally and when it is beginning to deviate. Good maternity care is not about avoiding intervention; it is about intervening at the right time, for the right reasons, in genuine partnership with the woman. 

The Cost of a Misguided Debate 

If the public is led to believe that birth physiology itself is inherently unsafe, confidence in continuity of midwifery care, birth centres, and community-based services will be undermined, despite decades of evidence demonstrating their safety for appropriately selected women. We risk dismantling the very models of care associated with better outcomes because they have become caricatured. 

Complex systems rarely fail for a single reason. Aviation accidents, nuclear incidents, and major industrial disasters are seldom caused by one mistake; they arise when multiple layers of defense fail simultaneously. Maternity care is no different. The UK reports describe complex systems failures, not a single flawed philosophy. Perhaps the greatest lesson from these inquiries is not that maternity services over-supported physiology, but that they failed to create the organisational conditions in which physiology could be safely observed, understood, and supported. 

Reframing the Path Ahead 

To fix this, we need to completely reframe the debate: The opposite of intervention is not normal birth. The opposite of intervention is neglect. Good maternity care lies precisely between those extremes: understanding physiology well enough to support it when it is healthy and recognising early when it is no longer safe. This perspective moves us beyond the polarising language of "normal birth versus intervention" and towards what the inquiries consistently point to. Safer maternity care depends on well-functioning systems staffed by professionals who work collaboratively, listen to women, and act decisively when circumstances change. 

We already know what makes maternity care safer: continuity of relational midwifery care, adequate staffing, psychologically safe teams, respectful multidisciplinary collaboration, informed decision-making by the woman, and organisations that learn rather than blame. 

These elements are not in competition with physiological birth; they are the very conditions that enable physiology to be supported safely and intervention to occur when needed.

Creating Optimal Birth Space

The environment in which we live and move and have our being is critical to our physical, mental, spiritual and social functioning. More and more understanding is emerging about how the environment plays a pivotal role in all aspects of our lives. From mice to (wo) men, science is demonstrating that the body's neural network is "plastic", that genes are not destiny and that the "environment" is an integral part of how living creatures function and develop. Every physiological interaction and behaviour, from the way genes are expressed in the sperm and the ovum to our health and experience across the lifecycle depends upon the environment. The environnment gives feedback which will be either nourishing and provide the stimulus to function well and grow or hostile, which disrupts our functioning, leading to disease, distress and decay.

Recognition of the way the environment is integral to optimal functioning is expanding our understanding of the role of maternity care in providing optimal environments for childbearing women. The science is also demonstrating why woman centred care, facilitating the fulfilment of woman's choices and incorporating women's rights into maternity care are so much a part of optimising outcomes for women, their babies, their intimate relationships and society in general.

My friend and colleague, the wonderful Maralyn Foureur, Professor of Midwifery at the University of Technology of Sydney (UTS) presented on this topic at the recent homebirth conference in New Zealand.  Maralyn is heading up a research team exploring birth space and has attracted a highly prized NHMRC grant for this work. 

Click the link below and it will take you to the slide share of her presentation

Creating Optimal Birth Space

I think you will enjoy and get a lot out of her research.